{"id":2747,"date":"2021-02-19T17:31:56","date_gmt":"2021-02-19T20:31:56","guid":{"rendered":"https:\/\/www.newstar.com.br\/?page_id=2747"},"modified":"2021-02-19T19:25:39","modified_gmt":"2021-02-19T22:25:39","slug":"formulario-anamnese-naturopatia","status":"publish","type":"page","link":"https:\/\/www.newstar.com.br\/index.php\/agendamento\/formularios-anamnese\/formulario-anamnese-naturopatia\/","title":{"rendered":"Formul\u00e1rio Anamnese Naturopatia"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|tablet&#8221; admin_label=&#8221;Header&#8221; _builder_version=&#8221;4.5.7&#8243; background_enable_image=&#8221;off&#8221; background_size=&#8221;contain&#8221; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;28px||0px||false|false&#8221; custom_padding_tablet=&#8221;0px||||false|false&#8221; custom_padding_phone=&#8221;&#8221; locked=&#8221;off&#8221; collapsed=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.5.7&#8243; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;||0px||false|false&#8221; collapsed=&#8221;on&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.5.7&#8243; custom_padding=&#8221;||30px||false|false&#8221; custom_padding_tablet=&#8221;||0px||false|false&#8221; custom_padding_phone=&#8221;||0px||false|false&#8221; custom_padding_last_edited=&#8221;on|phone&#8221;][et_pb_text admin_label=&#8221;T\u00edtulo&#8221; _builder_version=&#8221;4.9.0&#8243; header_font_size=&#8221;55px&#8221; header_line_height=&#8221;1.2em&#8221; header_font_tablet=&#8221;Muli|600|||||||&#8221; header_font_phone=&#8221;&#8221; header_font_last_edited=&#8221;on|desktop&#8221; header_text_align_tablet=&#8221;&#8221; header_text_align_phone=&#8221;center&#8221; header_text_align_last_edited=&#8221;on|phone&#8221; header_font_size_tablet=&#8221;38px&#8221; header_font_size_phone=&#8221;32px&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; header_letter_spacing_tablet=&#8221;2px&#8221; header_letter_spacing_phone=&#8221;0px&#8221; header_letter_spacing_last_edited=&#8221;on|desktop&#8221; header_text_shadow_style=&#8221;preset3&#8243; header_text_shadow_color=&#8221;#ffffff&#8221; locked=&#8221;off&#8221;]<\/p>\n<h1>Formul\u00e1rio Anamnese<\/h1>\n<h2>Aromaterapia<\/h2>\n<h2>Florais de Bach<\/h2>\n<h2>Fitoterapia<\/h2>\n<h2>Homeopatia<\/h2>\n<p>[\/et_pb_text][et_pb_divider color=&#8221;#7cc68d&#8221; divider_weight=&#8221;2px&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; width=&#8221;150px&#8221; custom_margin=&#8221;15px||||false|false&#8221; module_alignment_tablet=&#8221;&#8221; module_alignment_phone=&#8221;center&#8221; module_alignment_last_edited=&#8221;on|phone&#8221;][\/et_pb_divider][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Descri\u00e7\u00e3o&#8221; _builder_version=&#8221;4.5.7&#8243; background_color=&#8221;#f7f7f7&#8243; background_enable_image=&#8221;off&#8221; background_size=&#8221;contain&#8221; custom_padding=&#8221;0px||0px|||&#8221; locked=&#8221;off&#8221; collapsed=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; collapsed=&#8221;on&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_text _builder_version=&#8221;4.9.0&#8243; text_font_size=&#8221;15px&#8221; header_font=&#8221;Abel||||||||&#8221; header_text_color=&#8221;#8f5f25&#8243; header_font_size=&#8221;20px&#8221; header_line_height=&#8221;1.4em&#8221; header_4_font=&#8221;Abel||||||||&#8221; header_4_text_color=&#8221;#8f5f25&#8243; header_4_font_size=&#8221;20px&#8221; header_4_line_height=&#8221;1.4em&#8221; custom_margin=&#8221;||||false|false&#8221; custom_margin_tablet=&#8221;0px||0px||false|false&#8221; custom_margin_phone=&#8221;&#8221; custom_margin_last_edited=&#8221;on|tablet&#8221; custom_padding=&#8221;||0px||false|false&#8221; hover_enabled=&#8221;0&#8243; header_font_size_tablet=&#8221;20px&#8221; header_font_size_phone=&#8221;17px&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; header_4_font_size_tablet=&#8221;&#8221; header_4_font_size_phone=&#8221;18px&#8221; header_4_font_size_last_edited=&#8221;on|phone&#8221; sticky_enabled=&#8221;0&#8243;]<div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF603020f491e20\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/www.newstar.com.br\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF603020f491e20 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF603020f491e20_1\" data-form-id=\"CF603020f491e20\" aria-label=\"Anamnese de Naturopatia\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF603020f491e20-tmpl\" data-cfajax=\"CF603020f491e20\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/www.newstar.com.br\/cf-api\/CF603020f491e20\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF603020f491e20\" name=\"_cf_verify\" value=\"59e59003b1\"  data-nonce-time=\"1790147244\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2747\" \/><div id=\"cf2-CF603020f491e20_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF603020f491e20\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF603020f491e20\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"2747\">\r\n<span class=\"caldera-grid\"><ol class=\"breadcrumb\" data-form=\"caldera_form_1\" id=\"caldera-forms-breadcrumb_1\">\r\n<li class=\"active\"><a aria-controls=\"form_page_1_pg_1\" aria-expanded=\"true\" id=\"breadcrumb_1_pg_1\" href=\"?cf_pg=1\" data-page=\"1\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Dados Pessoais\">Dados Pessoais<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_2\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_2\" href=\"?cf_pg=2\" data-page=\"2\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Dados Complementares\">Dados Complementares<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_3\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_3\" href=\"?cf_pg=3\" data-page=\"3\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Dados Terapia\">Dados Terapia<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_4\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_4\" href=\"?cf_pg=4\" data-page=\"4\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Estilo de Vida\">Estilo de Vida<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_5\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_5\" href=\"?cf_pg=5\" data-page=\"5\" data-pagenav=\"caldera_form_1\" title=\"Navigate to H\u00e1bitos Alimentares\">H\u00e1bitos Alimentares<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_6\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_6\" href=\"?cf_pg=6\" data-page=\"6\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Sa\u00fade Familiar 1\">Sa\u00fade Familiar 1<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_7\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_7\" href=\"?cf_pg=7\" data-page=\"7\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Sa\u00fade Familiar 2\">Sa\u00fade Familiar 2<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_8\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_8\" href=\"?cf_pg=8\" data-page=\"8\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Sintomas F\u00edsicos 1\">Sintomas F\u00edsicos 1<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_9\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_9\" href=\"?cf_pg=9\" data-page=\"9\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Sintomas F\u00edsicos 2\">Sintomas F\u00edsicos 2<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_10\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_10\" href=\"?cf_pg=10\" data-page=\"10\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Vis\u00e3o Pessoal\">Vis\u00e3o Pessoal<\/a><\/li>\r\n<li><a aria-controls=\"form_page_1_pg_11\" aria-expanded=\"false\" id=\"breadcrumb_1_pg_11\" href=\"?cf_pg=11\" data-page=\"11\" data-pagenav=\"caldera_form_1\" title=\"Navigate to Perfil Psicol\u00f3gico\">Perfil Psicol\u00f3gico<\/a><\/li>\r\n<\/ol><\/span>\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>E-mail<\/label><input type=\"text\" name=\"email\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"form_page_1_pg_1\" data-formpage=\"1\" class=\"caldera-form-page\" style=\"display:block;\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_1\" aria-hidden=\"false\"><div id=\"CF603020f491e20_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9348355\" class=\"form-group\" id=\"fld_9348355_1-wrap\">\r\n\t<label id=\"fld_9348355Label\" for=\"fld_9348355_1\" class=\"control-label\">E-mail <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_9348355\" class=\" form-control\" id=\"fld_9348355_1\" name=\"fld_9348355\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_9348355Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7732289\" class=\"form-group\" id=\"fld_7732289_1-wrap\">\r\n\t<label id=\"fld_7732289Label\" for=\"fld_7732289_1\" class=\"control-label\">Nome Completo <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7732289\" class=\" form-control\" id=\"fld_7732289_1\" name=\"fld_7732289\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7732289Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-2\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5587279\" class=\"form-group\" id=\"fld_5587279_1-wrap\">\r\n\t<label id=\"fld_5587279Label\" for=\"fld_5587279_1\" class=\"control-label\">N\u00famero Identidade <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '[9{*}]'\"  required type=\"text\" data-field=\"fld_5587279\" class=\" form-control\" id=\"fld_5587279_1\" name=\"fld_5587279\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5587279Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_4455205\" class=\"form-group\" id=\"fld_4455205_1-wrap\">\r\n\t<label id=\"fld_4455205Label\" for=\"fld_4455205_1\" class=\"control-label\">CPF <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '999.999.999\/99'\"  required type=\"text\" data-field=\"fld_4455205\" class=\" form-control\" id=\"fld_4455205_1\" name=\"fld_4455205\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4455205Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3535274\" class=\"form-group\" id=\"fld_3535274_1-wrap\">\r\n\t<label id=\"fld_3535274Label\" for=\"fld_3535274_1\" class=\"control-label\">Telefone <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"tel\" data-field=\"fld_3535274\" class=\" form-control\" id=\"fld_3535274_1\" name=\"fld_3535274\" value=\"\" data-type=\"phone_better\" aria-required=\"true\"   aria-labelledby=\"fld_3535274Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1165696\" class=\"form-group\" id=\"fld_1165696_1-wrap\">\r\n\t<label id=\"fld_1165696Label\" for=\"fld_1165696_1\" class=\"control-label\">Telefone Emerg\u00eancia <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"tel\" data-field=\"fld_1165696\" class=\" form-control\" id=\"fld_1165696_1\" name=\"fld_1165696\" value=\"\" data-type=\"phone_better\" aria-required=\"true\"   aria-labelledby=\"fld_1165696Label\" aria-describedby=\"fld_1165696Caption\" >\t\t<span id=\"fld_1165696Caption\" class=\"help-block\">(De pessoa pr\u00f3xima para caso de doen\u00e7a ou problema card\u00edaco,  convuls\u00e3o, epilepsia, depress\u00e3o ou taquicardia)<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \">\n<div data-field-wrapper=\"fld_1898311\" class=\"form-group\" id=\"fld_1898311_1-wrap\">\r\n\t<label id=\"fld_1898311Label\" for=\"fld_1898311_1\" class=\"control-label\">Data de Nascimento <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  type=\"text\" data-provide=\"cfdatepicker\" name=\"fld_1898311\" value=\"\" id=\"fld_1898311_1\" data-field=\"fld_1898311\" class=\"form-control cfdatepicker is-cfdatepicker\" data-date-format=\"dd-mm-yyyy\" required=\"1\" data-date-start-view=\"month\"  data-date-start-date=\"-100y\" data-date-end-date=\"0d\" data-date-language=\"pt-BR\"   aria-labelledby=\"fld_1898311Label\" required  \/>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2200576\" class=\"form-group\" id=\"fld_2200576_1-wrap\">\r\n<label id=\"fld_2200576Label\" for=\"fld_2200576_1\" class=\"control-label\">Sexo Biol\u00f3gico <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Masculino\" for=\"fld_2200576_1_opt1079885\"><input type=\"radio\" id=\"fld_2200576_1_opt1079885\" data-field=\"fld_2200576\" class=\"fld_2200576_1 option-required\" name=\"fld_2200576\" value=\"Masculino\"   required=\"required\" data-radio-field=\"fld_2200576_1\" data-type=\"radio\" data-calc-value=\"Masculino\" \/>\n\t\t\tMasculino\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Feminino\" for=\"fld_2200576_1_opt1850032\"><input type=\"radio\" id=\"fld_2200576_1_opt1850032\" data-field=\"fld_2200576\" class=\"fld_2200576_1 option-required\" name=\"fld_2200576\" value=\"Feminino\"   required=\"required\" data-radio-field=\"fld_2200576_1\" data-type=\"radio\" data-calc-value=\"Feminino\" \/>\n\t\t\tFeminino\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1574495\" class=\"form-group\" id=\"fld_1574495_1-wrap\">\r\n<label id=\"fld_1574495Label\" for=\"fld_1574495_1\" class=\"control-label\">Estado Civil <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Solteiro(a)\" for=\"fld_1574495_1_opt1616306\"><input type=\"radio\" id=\"fld_1574495_1_opt1616306\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Solteiro(a)\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Solteiro(a)\" \/>\n\t\t\tSolteiro(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Casado(a)\" for=\"fld_1574495_1_opt1371399\"><input type=\"radio\" id=\"fld_1574495_1_opt1371399\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Casado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Casado(a)\" \/>\n\t\t\tCasado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Separado(a)\" for=\"fld_1574495_1_opt1432735\"><input type=\"radio\" id=\"fld_1574495_1_opt1432735\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Separado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Separado(a)\" \/>\n\t\t\tSeparado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Divorciado(a)\" for=\"fld_1574495_1_opt1418034\"><input type=\"radio\" id=\"fld_1574495_1_opt1418034\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Divorciado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Divorciado(a)\" \/>\n\t\t\tDivorciado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Vi\u00favo(a)\" for=\"fld_1574495_1_opt1437975\"><input type=\"radio\" id=\"fld_1574495_1_opt1437975\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Vi\u00favo(a)\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Vi\u00favo(a)\" \/>\n\t\t\tVi\u00favo(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Uni\u00e3o Est\u00e1vel\" for=\"fld_1574495_1_opt1535754\"><input type=\"radio\" id=\"fld_1574495_1_opt1535754\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Uni\u00e3o Est\u00e1vel\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Uni\u00e3o Est\u00e1vel\" \/>\n\t\t\tUni\u00e3o Est\u00e1vel\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_1574495_1_opt1603568\"><input type=\"radio\" id=\"fld_1574495_1_opt1603568\" data-field=\"fld_1574495\" class=\"fld_1574495_1 option-required\" name=\"fld_1574495\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_1574495_1\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9442215_1\" data-field-id=\"fld_9442215_1\"><\/span><\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_3473230\" class=\"form-group\" id=\"fld_3473230_1-wrap\">\r\n<label id=\"fld_3473230Label\" for=\"fld_3473230_1\" class=\"control-label\">Escolaridade <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino B\u00e1sico Incompleto\" for=\"fld_3473230_1_opt1962342\"><input type=\"radio\" id=\"fld_3473230_1_opt1962342\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino B\u00e1sico Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino B\u00e1sico Incompleto\" \/>\n\t\t\tEnsino B\u00e1sico Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino B\u00e1sico Completo\" for=\"fld_3473230_1_opt1738137\"><input type=\"radio\" id=\"fld_3473230_1_opt1738137\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino B\u00e1sico Completo\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino B\u00e1sico Completo\" \/>\n\t\t\tEnsino B\u00e1sico Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino M\u00e9dio Incompleto\" for=\"fld_3473230_1_opt1822752\"><input type=\"radio\" id=\"fld_3473230_1_opt1822752\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino M\u00e9dio Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino M\u00e9dio Incompleto\" \/>\n\t\t\tEnsino M\u00e9dio Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino M\u00e9dio Completo\" for=\"fld_3473230_1_opt1144506\"><input type=\"radio\" id=\"fld_3473230_1_opt1144506\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino M\u00e9dio Completo\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino M\u00e9dio Completo\" \/>\n\t\t\tEnsino M\u00e9dio Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino Superior Incompleto\" for=\"fld_3473230_1_opt1219521\"><input type=\"radio\" id=\"fld_3473230_1_opt1219521\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino Superior Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino Superior Incompleto\" \/>\n\t\t\tEnsino Superior Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino Superior Completo\" for=\"fld_3473230_1_opt1707489\"><input type=\"radio\" id=\"fld_3473230_1_opt1707489\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Ensino Superior Completo\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Ensino Superior Completo\" \/>\n\t\t\tEnsino Superior Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"P\u00f3s Gradua\u00e7\u00e3o\" for=\"fld_3473230_1_opt1416217\"><input type=\"radio\" id=\"fld_3473230_1_opt1416217\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"P\u00f3s Gradua\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"P\u00f3s Gradua\u00e7\u00e3o\" \/>\n\t\t\tP\u00f3s Gradua\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Doutorado\" for=\"fld_3473230_1_opt1881869\"><input type=\"radio\" id=\"fld_3473230_1_opt1881869\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Doutorado\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Doutorado\" \/>\n\t\t\tDoutorado\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"P\u00f3s Doutorado\" for=\"fld_3473230_1_opt1550592\"><input type=\"radio\" id=\"fld_3473230_1_opt1550592\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"P\u00f3s Doutorado\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"P\u00f3s Doutorado\" \/>\n\t\t\tP\u00f3s Doutorado\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_3473230_1_opt1815639\"><input type=\"radio\" id=\"fld_3473230_1_opt1815639\" data-field=\"fld_3473230\" class=\"fld_3473230_1 option-required\" name=\"fld_3473230\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_3473230_1\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7633772_1\" data-field-id=\"fld_7633772_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-3\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9052200\" class=\"form-group\" id=\"fld_9052200_1-wrap\">\r\n\t<label id=\"fld_9052200Label\" for=\"fld_9052200_1\" class=\"control-label\">Profiss\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9052200\" class=\" form-control\" id=\"fld_9052200_1\" name=\"fld_9052200\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9052200Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-4\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4776983\" class=\"form-group\" id=\"fld_4776983_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_4776983\" id=\"fld_4776983_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_4776983\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_4776983\" id=\"fld_4776983_1_btn\" value=\"\" data-field=\"fld_4776983\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9332146\" class=\"form-group\" id=\"fld_9332146_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_9332146\" id=\"fld_9332146_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_9332146\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_9332146\" id=\"fld_9332146_1_btn\" value=\"\" data-field=\"fld_9332146\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_2\" data-formpage=\"2\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_2\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-5\"  class=\"row \"><div  class=\"col-sm-12  single\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_783295_1\" data-field-id=\"fld_783295_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-6\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_8364991\" class=\"form-group\" id=\"fld_8364991_1-wrap\">\r\n<label id=\"fld_8364991Label\" for=\"fld_8364991_1\" class=\"control-label\">Possui Filhos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_8364991_1_opt2033469\"><input type=\"radio\" id=\"fld_8364991_1_opt2033469\" data-field=\"fld_8364991\" class=\"fld_8364991_1 option-required\" name=\"fld_8364991\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_8364991_1\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o\" for=\"fld_8364991_1_opt1637251\"><input type=\"radio\" id=\"fld_8364991_1_opt1637251\" data-field=\"fld_8364991\" class=\"fld_8364991_1 option-required\" name=\"fld_8364991\" value=\"N\u00e3o\"   required=\"required\" data-radio-field=\"fld_8364991_1\" data-type=\"radio\" data-calc-value=\"N\u00e3o\" \/>\n\t\t\tN\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1576420_1\" data-field-id=\"fld_1576420_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9024547_1\" data-field-id=\"fld_9024547_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-7\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4386765\" class=\"form-group\" id=\"fld_4386765_1-wrap\">\r\n\t<label id=\"fld_4386765Label\" for=\"fld_4386765_1\" class=\"control-label\">Peso Aproximado <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '999,99'\"  required type=\"text\" data-field=\"fld_4386765\" class=\" form-control\" id=\"fld_4386765_1\" name=\"fld_4386765\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4386765Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9513699\" class=\"form-group\" id=\"fld_9513699_1-wrap\">\r\n\t<label id=\"fld_9513699Label\" for=\"fld_9513699_1\" class=\"control-label\">Altura Aproximada <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9513699\" class=\" form-control\" id=\"fld_9513699_1\" name=\"fld_9513699\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9513699Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3187774\" class=\"form-group\" id=\"fld_3187774_1-wrap\">\r\n<label id=\"fld_3187774Label\" for=\"fld_3187774_1\" class=\"control-label\">Press\u00e3o Arterial <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Baixa descontrolada\" for=\"fld_3187774_1_opt1653029\"><input type=\"radio\" id=\"fld_3187774_1_opt1653029\" data-field=\"fld_3187774\" class=\"fld_3187774_1 option-required\" name=\"fld_3187774\" value=\"Baixa descontrolada\"   required=\"required\" data-radio-field=\"fld_3187774_1\" data-type=\"radio\" data-calc-value=\"Baixa descontrolada\" \/>\n\t\t\tBaixa descontrolada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Baixa controlada\" for=\"fld_3187774_1_opt1623201\"><input type=\"radio\" id=\"fld_3187774_1_opt1623201\" data-field=\"fld_3187774\" class=\"fld_3187774_1 option-required\" name=\"fld_3187774\" value=\"Baixa controlada\"   required=\"required\" data-radio-field=\"fld_3187774_1\" data-type=\"radio\" data-calc-value=\"Baixa controlada\" \/>\n\t\t\tBaixa controlada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Normal\" for=\"fld_3187774_1_opt1373188\"><input type=\"radio\" id=\"fld_3187774_1_opt1373188\" data-field=\"fld_3187774\" class=\"fld_3187774_1 option-required\" name=\"fld_3187774\" value=\"Normal\"   required=\"required\" data-radio-field=\"fld_3187774_1\" data-type=\"radio\" data-calc-value=\"Normal\" \/>\n\t\t\tNormal\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Alta controlada\" for=\"fld_3187774_1_opt1381318\"><input type=\"radio\" id=\"fld_3187774_1_opt1381318\" data-field=\"fld_3187774\" class=\"fld_3187774_1 option-required\" name=\"fld_3187774\" value=\"Alta controlada\"   required=\"required\" data-radio-field=\"fld_3187774_1\" data-type=\"radio\" data-calc-value=\"Alta controlada\" \/>\n\t\t\tAlta controlada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Alta descontrolada\" for=\"fld_3187774_1_opt1506692\"><input type=\"radio\" id=\"fld_3187774_1_opt1506692\" data-field=\"fld_3187774\" class=\"fld_3187774_1 option-required\" name=\"fld_3187774\" value=\"Alta descontrolada\"   required=\"required\" data-radio-field=\"fld_3187774_1\" data-type=\"radio\" data-calc-value=\"Alta descontrolada\" \/>\n\t\t\tAlta descontrolada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-8\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_2473029\" class=\"form-group\" id=\"fld_2473029_1-wrap\">\r\n\t<label id=\"fld_2473029Label\" for=\"fld_2473029_1\" class=\"control-label\">Religi\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2473029\" class=\" form-control\" id=\"fld_2473029_1\" name=\"fld_2473029\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2473029Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-9\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_9471700\" class=\"form-group\" id=\"fld_9471700_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_9471700\" id=\"fld_9471700_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_9471700\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_9471700\" id=\"fld_9471700_1_btn\" value=\"\" data-field=\"fld_9471700\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9215733\" class=\"form-group\" id=\"fld_9215733_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_9215733\" id=\"fld_9215733_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_9215733\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_9215733\" id=\"fld_9215733_1_btn\" value=\"\" data-field=\"fld_9215733\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6439464\" class=\"form-group\" id=\"fld_6439464_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_6439464\" id=\"fld_6439464_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_6439464\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_6439464\" id=\"fld_6439464_1_btn\" value=\"\" data-field=\"fld_6439464\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_3\" data-formpage=\"3\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_3\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-10\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_4594027\" class=\"form-group\" id=\"fld_4594027_1-wrap\">\r\n\t<label id=\"fld_4594027Label\" for=\"fld_4594027_1\" class=\"control-label\">Problema principal ou raz\u00f5es para a consulta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_4594027\" value=\"\" data-field=\"fld_4594027\" class=\"form-control\" id=\"fld_4594027_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_4594027Label\" aria-describedby=\"fld_4594027Caption\" ><\/textarea>\n\t\t<span id=\"fld_4594027Caption\" class=\"help-block\">Liste em ordem de import\u00e2ncia para voc\u00ea, quando come\u00e7aram, se possuem uma localiza\u00e7\u00e3o espec\u00edfica no corpo, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7586584\" class=\"form-group\" id=\"fld_7586584_1-wrap\">\r\n\t<label id=\"fld_7586584Label\" for=\"fld_7586584_1\" class=\"control-label\">Problemas adicionais ou preocupa\u00e7\u00f5es que voc\u00ea gostaria de abordar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7586584\" value=\"\" data-field=\"fld_7586584\" class=\"form-control\" id=\"fld_7586584_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7586584Label\" aria-describedby=\"fld_7586584Caption\" ><\/textarea>\n\t\t<span id=\"fld_7586584Caption\" class=\"help-block\">Nota : N\u00e3o \u00e9 poss\u00edvel resolver todos os problemas no decurso de um tratamento<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-11\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7159025\" class=\"form-group\" id=\"fld_7159025_1-wrap\">\r\n\t<label id=\"fld_7159025Label\" for=\"fld_7159025_1\" class=\"control-label\">Em quais situa\u00e7\u00f5es os sintomas se agravam? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1752501\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Ao falar\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1752501\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1752501]\"\n                                value=\"Ao falar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Ao falar\"\n                            >\n                    Ao falar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2029163\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Ao usar roupas apertadas\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2029163\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2029163]\"\n                                value=\"Ao usar roupas apertadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Ao usar roupas apertadas\"\n                            >\n                    Ao usar roupas apertadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1171381\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Quando n\u00e3o se alimenta corretamente\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1171381\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1171381]\"\n                                value=\"Quando n\u00e3o se alimenta corretamente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Quando n\u00e3o se alimenta corretamente\"\n                            >\n                    Quando n\u00e3o se alimenta corretamente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1994714\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Durante sua higiene pessoal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1994714\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1994714]\"\n                                value=\"Durante sua higiene pessoal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Durante sua higiene pessoal\"\n                            >\n                    Durante sua higiene pessoal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1108483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1108483\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1108483]\"\n                                value=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                            >\n                    Durante a menstrua\u00e7\u00e3o em tempo frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2081411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Manh\u00e3\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2081411\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2081411]\"\n                                value=\"Manh\u00e3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Manh\u00e3\"\n                            >\n                    Manh\u00e3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1943003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Noite\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1943003\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1943003]\"\n                                value=\"Noite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Noite\"\n                            >\n                    Noite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1487906\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Na cama\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1487906\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1487906]\"\n                                value=\"Na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Na cama\"\n                            >\n                    Na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1454147\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Deitado de costas\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1454147\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1454147]\"\n                                value=\"Deitado de costas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Deitado de costas\"\n                            >\n                    Deitado de costas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1104081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Deitado no lado afetado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1104081\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1104081]\"\n                                value=\"Deitado no lado afetado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Deitado no lado afetado\"\n                            >\n                    Deitado no lado afetado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2029059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2029059\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2029059]\"\n                                value=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                            >\n                    Quando muda de posi\u00e7\u00e3o na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1221576\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Durante o repouso\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1221576\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1221576]\"\n                                value=\"Durante o repouso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Durante o repouso\"\n                            >\n                    Durante o repouso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1580283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Durante o sono\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1580283\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1580283]\"\n                                value=\"Durante o sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Durante o sono\"\n                            >\n                    Durante o sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1653981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Durante exerc\u00edcios\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1653981\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1653981]\"\n                                value=\"Durante exerc\u00edcios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Durante exerc\u00edcios\"\n                            >\n                    Durante exerc\u00edcios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2031475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Em clima frio\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2031475\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2031475]\"\n                                value=\"Em clima frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Em clima frio\"\n                            >\n                    Em clima frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2096252\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Em clima \u00famido\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2096252\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2096252]\"\n                                value=\"Em clima \u00famido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Em clima \u00famido\"\n                            >\n                    Em clima \u00famido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1879459\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Mudan\u00e7as de temperatura\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1879459\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1879459]\"\n                                value=\"Mudan\u00e7as de temperatura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Mudan\u00e7as de temperatura\"\n                            >\n                    Mudan\u00e7as de temperatura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1742522\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Antes de um temporal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1742522\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1742522]\"\n                                value=\"Antes de um temporal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Antes de um temporal\"\n                            >\n                    Antes de um temporal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1646665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Depois de um temporal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1646665\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1646665]\"\n                                value=\"Depois de um temporal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Depois de um temporal\"\n                            >\n                    Depois de um temporal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1833258\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Na primavera\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1833258\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1833258]\"\n                                value=\"Na primavera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Na primavera\"\n                            >\n                    Na primavera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1953926\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"No ver\u00e3o\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1953926\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1953926]\"\n                                value=\"No ver\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"No ver\u00e3o\"\n                            >\n                    No ver\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1100701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"No outono\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1100701\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1100701]\"\n                                value=\"No outono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"No outono\"\n                            >\n                    No outono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1624371\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"No inverno\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1624371\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1624371]\"\n                                value=\"No inverno\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"No inverno\"\n                            >\n                    No inverno                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1986441\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Exposto a luz do Sol\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1986441\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1986441]\"\n                                value=\"Exposto a luz do Sol\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Exposto a luz do Sol\"\n                            >\n                    Exposto a luz do Sol                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1421716\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Na praia ou no mar\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1421716\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1421716]\"\n                                value=\"Na praia ou no mar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Na praia ou no mar\"\n                            >\n                    Na praia ou no mar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1923481\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Em ambiente quente ou abafado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1923481\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1923481]\"\n                                value=\"Em ambiente quente ou abafado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Em ambiente quente ou abafado\"\n                            >\n                    Em ambiente quente ou abafado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2035402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Em ambiente fechado ou lotado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2035402\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2035402]\"\n                                value=\"Em ambiente fechado ou lotado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Em ambiente fechado ou lotado\"\n                            >\n                    Em ambiente fechado ou lotado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt2089671\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Cheiro de tabaco\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt2089671\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt2089671]\"\n                                value=\"Cheiro de tabaco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Cheiro de tabaco\"\n                            >\n                    Cheiro de tabaco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_1_opt1936618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_1\" data-parsley-multiple=\"fld_7159025_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_1_opt1936618\"\n                                class=\"fld_7159025_1 option-required\"\n                                name=\"fld_7159025[opt1936618]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3885880_1\" data-field-id=\"fld_3885880_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6367522\" class=\"form-group\" id=\"fld_6367522_1-wrap\">\r\n\t<label id=\"fld_6367522Label\" for=\"fld_6367522_1\" class=\"control-label\">Em quais situa\u00e7\u00f5es os sintomas melhoram? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1339328\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Quando se alimenta\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1339328\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1339328]\"\n                                value=\"Quando se alimenta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Quando se alimenta\"\n                            >\n                    Quando se alimenta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1968472\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Quando fica sozinho\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1968472\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1968472]\"\n                                value=\"Quando fica sozinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Quando fica sozinho\"\n                            >\n                    Quando fica sozinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1183368\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Ao ouvir m\u00fasica\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1183368\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1183368]\"\n                                value=\"Ao ouvir m\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Ao ouvir m\u00fasica\"\n                            >\n                    Ao ouvir m\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1893677\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Aplicando press\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1893677\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1893677]\"\n                                value=\"Aplicando press\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Aplicando press\u00e3o\"\n                            >\n                    Aplicando press\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1415624\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Aplicando compressas frias\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1415624\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1415624]\"\n                                value=\"Aplicando compressas frias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Aplicando compressas frias\"\n                            >\n                    Aplicando compressas frias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1298411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Aplicando compressas quentes\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1298411\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1298411]\"\n                                value=\"Aplicando compressas quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Aplicando compressas quentes\"\n                            >\n                    Aplicando compressas quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1128783\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Ao dobrar-se ou contorcer-se\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1128783\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1128783]\"\n                                value=\"Ao dobrar-se ou contorcer-se\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Ao dobrar-se ou contorcer-se\"\n                            >\n                    Ao dobrar-se ou contorcer-se                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1260413\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Virando para tr\u00e1s\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1260413\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1260413]\"\n                                value=\"Virando para tr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Virando para tr\u00e1s\"\n                            >\n                    Virando para tr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1443326\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Manh\u00e3\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1443326\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1443326]\"\n                                value=\"Manh\u00e3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Manh\u00e3\"\n                            >\n                    Manh\u00e3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1956207\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Noite\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1956207\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1956207]\"\n                                value=\"Noite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Noite\"\n                            >\n                    Noite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1833104\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Madrugada\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1833104\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1833104]\"\n                                value=\"Madrugada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Madrugada\"\n                            >\n                    Madrugada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1546340\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Durante o repouso\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1546340\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1546340]\"\n                                value=\"Durante o repouso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Durante o repouso\"\n                            >\n                    Durante o repouso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1417686\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Destapando os p\u00e9s na cama\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1417686\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1417686]\"\n                                value=\"Destapando os p\u00e9s na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Destapando os p\u00e9s na cama\"\n                            >\n                    Destapando os p\u00e9s na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1404970\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Abrindo uma janela\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1404970\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1404970]\"\n                                value=\"Abrindo uma janela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Abrindo uma janela\"\n                            >\n                    Abrindo uma janela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1406169\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Ao ar livre\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1406169\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1406169]\"\n                                value=\"Ao ar livre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Ao ar livre\"\n                            >\n                    Ao ar livre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1206869\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Exposto a luz do Sol\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1206869\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1206869]\"\n                                value=\"Exposto a luz do Sol\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Exposto a luz do Sol\"\n                            >\n                    Exposto a luz do Sol                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1102018\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Durante o ver\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1102018\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1102018]\"\n                                value=\"Durante o ver\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Durante o ver\u00e3o\"\n                            >\n                    Durante o ver\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1209480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Na praia ou no mar\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1209480\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1209480]\"\n                                value=\"Na praia ou no mar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Na praia ou no mar\"\n                            >\n                    Na praia ou no mar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt2088186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Ao mudar-se\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt2088186\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt2088186]\"\n                                value=\"Ao mudar-se\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Ao mudar-se\"\n                            >\n                    Ao mudar-se                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1485411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1485411\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1485411]\"\n                                value=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                            >\n                    Quando inicia a menstrua\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_1_opt1919798\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_1\" data-parsley-multiple=\"fld_6367522_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_1_opt1919798\"\n                                class=\"fld_6367522_1 option-required\"\n                                name=\"fld_6367522[opt1919798]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6650295_1\" data-field-id=\"fld_6650295_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-12\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_5341049\" class=\"form-group\" id=\"fld_5341049_1-wrap\">\r\n\t<label id=\"fld_5341049Label\" for=\"fld_5341049_1\" class=\"control-label\">Medicamentos alop\u00e1ticos em uso <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5341049\" value=\"\" data-field=\"fld_5341049\" class=\"form-control\" id=\"fld_5341049_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_5341049Label\" aria-describedby=\"fld_5341049Caption\" ><\/textarea>\n\t\t<span id=\"fld_5341049Caption\" class=\"help-block\">A quanto tempo usa, qual a dose e numero de vezes por dia e como est\u00e1 se sentindo com o uso<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2967108\" class=\"form-group\" id=\"fld_2967108_1-wrap\">\r\n\t<label id=\"fld_2967108Label\" for=\"fld_2967108_1\" class=\"control-label\">Medicamentos alop\u00e1ticos que j\u00e1 utilizou no passado <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2967108\" value=\"\" data-field=\"fld_2967108\" class=\"form-control\" id=\"fld_2967108_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2967108Label\" aria-describedby=\"fld_2967108Caption\" ><\/textarea>\n\t\t<span id=\"fld_2967108Caption\" class=\"help-block\">A quanto tempo usou, qual a dose e numero de vezes por dia e como se sentiu com o uso (Se lembrar)<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6796582\" class=\"form-group\" id=\"fld_6796582_1-wrap\">\r\n\t<label id=\"fld_6796582Label\" for=\"fld_6796582_1\" class=\"control-label\">Quais vacinas voc\u00ea recebeu? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6796582\" value=\"\" data-field=\"fld_6796582\" class=\"form-control\" id=\"fld_6796582_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6796582Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9466148\" class=\"form-group\" id=\"fld_9466148_1-wrap\">\r\n\t<label id=\"fld_9466148Label\" for=\"fld_9466148_1\" class=\"control-label\">Fitoter\u00e1picos, homeop\u00e1ticos, vitaminas e suplementos em uso <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9466148\" value=\"\" data-field=\"fld_9466148\" class=\"form-control\" id=\"fld_9466148_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9466148Label\" aria-describedby=\"fld_9466148Caption\" ><\/textarea>\n\t\t<span id=\"fld_9466148Caption\" class=\"help-block\">A quanto tempo usa, qual a dose e n\u00famero de vezes por dia<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-13\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8952750\" class=\"form-group\" id=\"fld_8952750_1-wrap\">\r\n\t<label id=\"fld_8952750Label\" for=\"fld_8952750_1\" class=\"control-label\">Dispositivos que voc\u00ea usa <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1818115\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"\u00d3culos\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1818115\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1818115]\"\n                                value=\"\u00d3culos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"\u00d3culos\"\n                            >\n                    \u00d3culos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1813301\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Lente de contato\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1813301\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1813301]\"\n                                value=\"Lente de contato\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Lente de contato\"\n                            >\n                    Lente de contato                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1192683\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1192683\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1192683]\"\n                                value=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                            >\n                    Obtura\u00e7\u00e3o ou implante dent\u00e1rio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt2030644\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Dentadura\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt2030644\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt2030644]\"\n                                value=\"Dentadura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Dentadura\"\n                            >\n                    Dentadura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1453780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Aparelho auditivo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1453780\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1453780]\"\n                                value=\"Aparelho auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Aparelho auditivo\"\n                            >\n                    Aparelho auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1689357\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Pr\u00f3tese ou membro artificial\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1689357\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1689357]\"\n                                value=\"Pr\u00f3tese ou membro artificial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Pr\u00f3tese ou membro artificial\"\n                            >\n                    Pr\u00f3tese ou membro artificial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1120655\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Marcapasso\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1120655\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1120655]\"\n                                value=\"Marcapasso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Marcapasso\"\n                            >\n                    Marcapasso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1967343\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Stents card\u00edacos, vasculares ou uretrais\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1967343\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1967343]\"\n                                value=\"Stents card\u00edacos, vasculares ou uretrais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Stents card\u00edacos, vasculares ou uretrais\"\n                            >\n                    Stents card\u00edacos, vasculares ou uretrais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1399409\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Aparelho contraceptivo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1399409\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1399409]\"\n                                value=\"Aparelho contraceptivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Aparelho contraceptivo\"\n                            >\n                    Aparelho contraceptivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1179279\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Biochip\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1179279\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1179279]\"\n                                value=\"Biochip\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Biochip\"\n                            >\n                    Biochip                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1191531\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1191531\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1191531]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_1_opt1608887\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_1\" data-parsley-multiple=\"fld_8952750_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_1_opt1608887\"\n                                class=\"fld_8952750_1 option-required\"\n                                name=\"fld_8952750[opt1608887]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1530349_1\" data-field-id=\"fld_1530349_1\"><div data-field-wrapper=\"fld_1530349\" class=\"form-group\" id=\"fld_1530349_1-wrap\">\r\n\t<label id=\"fld_1530349Label\" for=\"fld_1530349_1\" class=\"control-label\">Complementar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1530349\" class=\" form-control\" id=\"fld_1530349_1\" name=\"fld_1530349\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1530349Label\" aria-describedby=\"fld_1530349Caption\" >\t\t<span id=\"fld_1530349Caption\" class=\"help-block\">Ex : Se possui obtura\u00e7\u00f5es, quantas? Se possui pr\u00f3tese ou membros artificiais, qual?<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5652515\" class=\"form-group\" id=\"fld_5652515_1-wrap\">\r\n\t<label id=\"fld_5652515Label\" for=\"fld_5652515_1\" class=\"control-label\">Hist\u00f3rico M\u00e9dico <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1365348\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Doen\u00e7a\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1365348\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1365348]\"\n                                value=\"Doen\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Doen\u00e7a\"\n                            >\n                    Doen\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1263132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Les\u00e3o\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1263132\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1263132]\"\n                                value=\"Les\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Les\u00e3o\"\n                            >\n                    Les\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1836715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Interna\u00e7\u00e3o\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1836715\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1836715]\"\n                                value=\"Interna\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Interna\u00e7\u00e3o\"\n                            >\n                    Interna\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1721430\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Cirurgia\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1721430\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1721430]\"\n                                value=\"Cirurgia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Cirurgia\"\n                            >\n                    Cirurgia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt2026537\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Trauma f\u00edsico\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt2026537\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt2026537]\"\n                                value=\"Trauma f\u00edsico\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Trauma f\u00edsico\"\n                            >\n                    Trauma f\u00edsico                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1167051\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1167051\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1167051]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_1_opt1694343\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_1\" data-parsley-multiple=\"fld_5652515_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_1_opt1694343\"\n                                class=\"fld_5652515_1 option-required\"\n                                name=\"fld_5652515[opt1694343]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3043002_1\" data-field-id=\"fld_3043002_1\"><div data-field-wrapper=\"fld_3043002\" class=\"form-group\" id=\"fld_3043002_1-wrap\">\r\n\t<label id=\"fld_3043002Label\" for=\"fld_3043002_1\" class=\"control-label\">Descreva o(s) hist\u00f3rico(s) m\u00e9dico(s) marcado(s) acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3043002\" value=\"\" data-field=\"fld_3043002\" class=\"form-control\" id=\"fld_3043002_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3043002Label\" aria-describedby=\"fld_3043002Caption\" ><\/textarea>\n\t\t<span id=\"fld_3043002Caption\" class=\"help-block\">Motivo, m\u00eas e ano, tempo de interna\u00e7\u00e3o, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-14\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4659334\" class=\"form-group\" id=\"fld_4659334_1-wrap\">\r\n\t<label id=\"fld_4659334Label\" for=\"fld_4659334_1\" class=\"control-label\">Alergias conhecidas <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1120778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1120778\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1120778]\"\n                                value=\"Alimentos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"Alimentos\"\n                            >\n                    Alimentos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1606026\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"P\u00f3len\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1606026\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1606026]\"\n                                value=\"P\u00f3len\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"P\u00f3len\"\n                            >\n                    P\u00f3len                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1091707\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"Odores\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1091707\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1091707]\"\n                                value=\"Odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"Odores\"\n                            >\n                    Odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1068315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1068315\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1068315]\"\n                                value=\"Rem\u00e9dios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"Rem\u00e9dios\"\n                            >\n                    Rem\u00e9dios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1456006\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"Animais\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1456006\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1456006]\"\n                                value=\"Animais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"Animais\"\n                            >\n                    Animais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1483014\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1483014\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1483014]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_1_opt1736147\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_1\" data-parsley-multiple=\"fld_4659334_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_1_opt1736147\"\n                                class=\"fld_4659334_1 option-required\"\n                                name=\"fld_4659334[opt1736147]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1619118_1\" data-field-id=\"fld_1619118_1\"><div data-field-wrapper=\"fld_1619118\" class=\"form-group\" id=\"fld_1619118_1-wrap\">\r\n\t<label id=\"fld_1619118Label\" for=\"fld_1619118_1\" class=\"control-label\">Fale sobre as alergias marcadas acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1619118\" value=\"\" data-field=\"fld_1619118\" class=\"form-control\" id=\"fld_1619118_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1619118Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-15\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_5814596\" class=\"form-group\" id=\"fld_5814596_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_5814596\" id=\"fld_5814596_1\" value=\"Pagina Anterior\" data-field=\"fld_5814596\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_5814596\" id=\"fld_5814596_1_btn\" value=\"\" data-field=\"fld_5814596\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6819459\" class=\"form-group\" id=\"fld_6819459_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_6819459\" id=\"fld_6819459_1\" value=\"Pagina Seguinte\" data-field=\"fld_6819459\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_6819459\" id=\"fld_6819459_1_btn\" value=\"\" data-field=\"fld_6819459\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4180018\" class=\"form-group\" id=\"fld_4180018_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_4180018\" id=\"fld_4180018_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_4180018\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_4180018\" id=\"fld_4180018_1_btn\" value=\"\" data-field=\"fld_4180018\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_4\" data-formpage=\"4\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_4\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-16\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8514796\" class=\"form-group\" id=\"fld_8514796_1-wrap\">\r\n<label id=\"fld_8514796Label\" for=\"fld_8514796_1\" class=\"control-label\">Como \u00e9 o seu relacionamento amoroso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Feliz\" for=\"fld_8514796_1_opt1823098\"><input type=\"radio\" id=\"fld_8514796_1_opt1823098\" data-field=\"fld_8514796\" class=\"fld_8514796_1 option-required\" name=\"fld_8514796\" value=\"Feliz\"   required=\"required\" data-radio-field=\"fld_8514796_1\" data-type=\"radio\" data-calc-value=\"Feliz\" \/>\n\t\t\tFeliz\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Exigente\" for=\"fld_8514796_1_opt1575060\"><input type=\"radio\" id=\"fld_8514796_1_opt1575060\" data-field=\"fld_8514796\" class=\"fld_8514796_1 option-required\" name=\"fld_8514796\" value=\"Exigente\"   required=\"required\" data-radio-field=\"fld_8514796_1\" data-type=\"radio\" data-calc-value=\"Exigente\" \/>\n\t\t\tExigente\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ciumento\" for=\"fld_8514796_1_opt1530874\"><input type=\"radio\" id=\"fld_8514796_1_opt1530874\" data-field=\"fld_8514796\" class=\"fld_8514796_1 option-required\" name=\"fld_8514796\" value=\"Ciumento\"   required=\"required\" data-radio-field=\"fld_8514796_1\" data-type=\"radio\" data-calc-value=\"Ciumento\" \/>\n\t\t\tCiumento\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Infeliz\" for=\"fld_8514796_1_opt1840198\"><input type=\"radio\" id=\"fld_8514796_1_opt1840198\" data-field=\"fld_8514796\" class=\"fld_8514796_1 option-required\" name=\"fld_8514796\" value=\"Infeliz\"   required=\"required\" data-radio-field=\"fld_8514796_1\" data-type=\"radio\" data-calc-value=\"Infeliz\" \/>\n\t\t\tInfeliz\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_8514796_1_opt1362757\"><input type=\"radio\" id=\"fld_8514796_1_opt1362757\" data-field=\"fld_8514796\" class=\"fld_8514796_1 option-required\" name=\"fld_8514796\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_8514796_1\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7494269_1\" data-field-id=\"fld_7494269_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_7513570\" class=\"form-group\" id=\"fld_7513570_1-wrap\">\r\n\t<label id=\"fld_7513570Label\" for=\"fld_7513570_1\" class=\"control-label\">Grandes tens\u00f5es emocionais nos \u00faltimos 2 anos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt2020930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Dinheiro\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt2020930\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt2020930]\"\n                                value=\"Dinheiro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Dinheiro\"\n                            >\n                    Dinheiro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt1233977\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Emprego\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt1233977\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt1233977]\"\n                                value=\"Emprego\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Emprego\"\n                            >\n                    Emprego                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt1176090\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Casamento\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt1176090\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt1176090]\"\n                                value=\"Casamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Casamento\"\n                            >\n                    Casamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt1634599\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Relacionamento familiar\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt1634599\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt1634599]\"\n                                value=\"Relacionamento familiar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Relacionamento familiar\"\n                            >\n                    Relacionamento familiar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt1834216\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt1834216\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt1834216]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_1_opt1818458\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_1\" data-parsley-multiple=\"fld_7513570_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_1_opt1818458\"\n                                class=\"fld_7513570_1 option-required\"\n                                name=\"fld_7513570[opt1818458]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6094755_1\" data-field-id=\"fld_6094755_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-17\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_3665933\" class=\"form-group\" id=\"fld_3665933_1-wrap\">\r\n\t<label id=\"fld_3665933Label\" for=\"fld_3665933_1\" class=\"control-label\">Hist\u00f3rico de viagens pertinentes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3665933\" value=\"\" data-field=\"fld_3665933\" class=\"form-control\" id=\"fld_3665933_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3665933Label\" aria-describedby=\"fld_3665933Caption\" ><\/textarea>\n\t\t<span id=\"fld_3665933Caption\" class=\"help-block\">Ao exterior, regi\u00f5es com epidemias, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-18\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5873470\" class=\"form-group\" id=\"fld_5873470_1-wrap\">\r\n\t<label id=\"fld_5873470Label\" for=\"fld_5873470_1\" class=\"control-label\">Possui algum v\u00edcio? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1731755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"\u00c1lcool\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1731755\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1731755]\"\n                                value=\"\u00c1lcool\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"\u00c1lcool\"\n                            >\n                    \u00c1lcool                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1674018\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Caf\u00e9\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1674018\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1674018]\"\n                                value=\"Caf\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Caf\u00e9\"\n                            >\n                    Caf\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1499379\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Chocolate\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1499379\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1499379]\"\n                                value=\"Chocolate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Chocolate\"\n                            >\n                    Chocolate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1788199\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Cigarro, charuto ou cachimbo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1788199\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1788199]\"\n                                value=\"Cigarro, charuto ou cachimbo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Cigarro, charuto ou cachimbo\"\n                            >\n                    Cigarro, charuto ou cachimbo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1576634\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Sexo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1576634\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1576634]\"\n                                value=\"Sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Sexo\"\n                            >\n                    Sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1594040\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios diet\u00e9ticos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1594040\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1594040]\"\n                                value=\"Rem\u00e9dios diet\u00e9ticos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Rem\u00e9dios diet\u00e9ticos\"\n                            >\n                    Rem\u00e9dios diet\u00e9ticos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1664849\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios sedativos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1664849\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1664849]\"\n                                value=\"Rem\u00e9dios sedativos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Rem\u00e9dios sedativos\"\n                            >\n                    Rem\u00e9dios sedativos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1138925\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Narc\u00f3ticos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1138925\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1138925]\"\n                                value=\"Narc\u00f3ticos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Narc\u00f3ticos\"\n                            >\n                    Narc\u00f3ticos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1580382\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Drogas\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1580382\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1580382]\"\n                                value=\"Drogas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Drogas\"\n                            >\n                    Drogas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1968125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1968125\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1968125]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_1_opt1902139\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_1\" data-parsley-multiple=\"fld_5873470_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_1_opt1902139\"\n                                class=\"fld_5873470_1 option-required\"\n                                name=\"fld_5873470[opt1902139]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2575749_1\" data-field-id=\"fld_2575749_1\"><div data-field-wrapper=\"fld_2575749\" class=\"form-group\" id=\"fld_2575749_1-wrap\">\r\n\t<label id=\"fld_2575749Label\" for=\"fld_2575749_1\" class=\"control-label\">Quais? Tem inten\u00e7\u00e3o de parar o uso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2575749\" value=\"\" data-field=\"fld_2575749\" class=\"form-control\" id=\"fld_2575749_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2575749Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7520435_1\" data-field-id=\"fld_7520435_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-19\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9183728\" class=\"form-group\" id=\"fld_9183728_1-wrap\">\r\n\t<label id=\"fld_9183728Label\" for=\"fld_9183728_1\" class=\"control-label\">Como lida com o estresse? Precisa de ajuda quanto a isso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9183728\" value=\"\" data-field=\"fld_9183728\" class=\"form-control\" id=\"fld_9183728_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9183728Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7404788\" class=\"form-group\" id=\"fld_7404788_1-wrap\">\r\n\t<label id=\"fld_7404788Label\" for=\"fld_7404788_1\" class=\"control-label\">Se exercita regularmente? Se n\u00e3o, porqu\u00ea? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7404788\" value=\"\" data-field=\"fld_7404788\" class=\"form-control\" id=\"fld_7404788_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7404788Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_4222683\" class=\"form-group\" id=\"fld_4222683_1-wrap\">\r\n\t<label id=\"fld_4222683Label\" for=\"fld_4222683_1\" class=\"control-label\">Voc\u00ea gosta de seu trabalho? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_4222683\" value=\"\" data-field=\"fld_4222683\" class=\"form-control\" id=\"fld_4222683_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_4222683Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3879322\" class=\"form-group\" id=\"fld_3879322_1-wrap\">\r\n\t<label id=\"fld_3879322Label\" for=\"fld_3879322_1\" class=\"control-label\">Voc\u00ea reserva tempo para descontrair e relaxar? Se n\u00e3o, porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3879322\" value=\"\" data-field=\"fld_3879322\" class=\"form-control\" id=\"fld_3879322_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3879322Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5641702\" class=\"form-group\" id=\"fld_5641702_1-wrap\">\r\n\t<label id=\"fld_5641702Label\" for=\"fld_5641702_1\" class=\"control-label\">Como \u00e9 seu sono? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5641702\" value=\"\" data-field=\"fld_5641702\" class=\"form-control\" id=\"fld_5641702_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_5641702Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6116219\" class=\"form-group\" id=\"fld_6116219_1-wrap\">\r\n\t<label id=\"fld_6116219Label\" for=\"fld_6116219_1\" class=\"control-label\">Est\u00e1 satisfeito com sua vida sexual? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6116219\" value=\"\" data-field=\"fld_6116219\" class=\"form-control\" id=\"fld_6116219_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6116219Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9783363\" class=\"form-group\" id=\"fld_9783363_1-wrap\">\r\n\t<label id=\"fld_9783363Label\" for=\"fld_9783363_1\" class=\"control-label\">Est\u00e1 satisfeito com sua vida social? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9783363\" value=\"\" data-field=\"fld_9783363\" class=\"form-control\" id=\"fld_9783363_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9783363Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_8755164\" class=\"form-group\" id=\"fld_8755164_1-wrap\">\r\n\t<label id=\"fld_8755164Label\" for=\"fld_8755164_1\" class=\"control-label\">Est\u00e1 satisfeito com sua vida religiosa\/espiritual? Porque?<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_8755164\" value=\"\" data-field=\"fld_8755164\" class=\"form-control\" id=\"fld_8755164_1\" rows=\"4\"    aria-labelledby=\"fld_8755164Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-20\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4636684\" class=\"form-group\" id=\"fld_4636684_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_4636684\" id=\"fld_4636684_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_4636684\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_4636684\" id=\"fld_4636684_1_btn\" value=\"\" data-field=\"fld_4636684\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_372783\" class=\"form-group\" id=\"fld_372783_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_372783\" id=\"fld_372783_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_372783\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_372783\" id=\"fld_372783_1_btn\" value=\"\" data-field=\"fld_372783\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_5043437\" class=\"form-group\" id=\"fld_5043437_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_5043437\" id=\"fld_5043437_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_5043437\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_5043437\" id=\"fld_5043437_1_btn\" value=\"\" data-field=\"fld_5043437\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_5\" data-formpage=\"5\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_5\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-21\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_544334\" class=\"form-group\" id=\"fld_544334_1-wrap\">\r\n<label id=\"fld_544334Label\" for=\"fld_544334_1\" class=\"control-label\">Como est\u00e1 seu apetite? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Bom\" for=\"fld_544334_1_opt1918307\"><input type=\"radio\" id=\"fld_544334_1_opt1918307\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Bom\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Bom\" \/>\n\t\t\tBom\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Diminuiu\" for=\"fld_544334_1_opt1108432\"><input type=\"radio\" id=\"fld_544334_1_opt1108432\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Diminuiu\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Diminuiu\" \/>\n\t\t\tDiminuiu\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Nunca sente fome\" for=\"fld_544334_1_opt1133680\"><input type=\"radio\" id=\"fld_544334_1_opt1133680\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Nunca sente fome\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Nunca sente fome\" \/>\n\t\t\tNunca sente fome\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Est\u00e1 sempre com fome\" for=\"fld_544334_1_opt1576919\"><input type=\"radio\" id=\"fld_544334_1_opt1576919\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Est\u00e1 sempre com fome\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Est\u00e1 sempre com fome\" \/>\n\t\t\tEst\u00e1 sempre com fome\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\" for=\"fld_544334_1_opt1672276\"><input type=\"radio\" id=\"fld_544334_1_opt1672276\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\" \/>\n\t\t\tN\u00e3o consegue terminar a refei\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\" for=\"fld_544334_1_opt2007610\"><input type=\"radio\" id=\"fld_544334_1_opt2007610\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\" \/>\n\t\t\tFome logo ap\u00f3s a refei\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_544334_1_opt1266308\"><input type=\"radio\" id=\"fld_544334_1_opt1266308\" data-field=\"fld_544334\" class=\"fld_544334_1 option-required\" name=\"fld_544334\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_544334_1\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_977328_1\" data-field-id=\"fld_977328_1\"><\/span><div data-field-wrapper=\"fld_3226139\" class=\"form-group\" id=\"fld_3226139_1-wrap\">\r\n\t<label id=\"fld_3226139Label\" for=\"fld_3226139_1\" class=\"control-label\">Ingere cafeina? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1883903\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Caf\u00e9\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1883903\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1883903]\"\n                                value=\"Caf\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Caf\u00e9\"\n                            >\n                    Caf\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1903978\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Ch\u00e1\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1903978\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1903978]\"\n                                value=\"Ch\u00e1\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Ch\u00e1\"\n                            >\n                    Ch\u00e1                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1475464\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Erva Mate\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1475464\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1475464]\"\n                                value=\"Erva Mate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Erva Mate\"\n                            >\n                    Erva Mate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1688200\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Refrigerante\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1688200\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1688200]\"\n                                value=\"Refrigerante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Refrigerante\"\n                            >\n                    Refrigerante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1768670\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Balas\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1768670\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1768670]\"\n                                value=\"Balas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Balas\"\n                            >\n                    Balas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1218190\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o consumo\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1218190\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1218190]\"\n                                value=\"N\u00e3o consumo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"N\u00e3o consumo\"\n                            >\n                    N\u00e3o consumo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_1_opt1382706\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_1\" data-parsley-multiple=\"fld_3226139_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_1_opt1382706\"\n                                class=\"fld_3226139_1 option-required\"\n                                name=\"fld_3226139[opt1382706]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2985878_1\" data-field-id=\"fld_2985878_1\"><\/span><div data-field-wrapper=\"fld_6437431\" class=\"form-group\" id=\"fld_6437431_1-wrap\">\r\n<label id=\"fld_6437431Label\" for=\"fld_6437431_1\" class=\"control-label\">Ingere bebidas alco\u00f3licas? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_6437431_1_opt1452404\"><input type=\"radio\" id=\"fld_6437431_1_opt1452404\" data-field=\"fld_6437431\" class=\"fld_6437431_1 option-required\" name=\"fld_6437431\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_6437431_1\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o, mas j\u00e1 ingeri\" for=\"fld_6437431_1_opt1978495\"><input type=\"radio\" id=\"fld_6437431_1_opt1978495\" data-field=\"fld_6437431\" class=\"fld_6437431_1 option-required\" name=\"fld_6437431\" value=\"N\u00e3o, mas j\u00e1 ingeri\"   required=\"required\" data-radio-field=\"fld_6437431_1\" data-type=\"radio\" data-calc-value=\"N\u00e3o, mas j\u00e1 ingeri\" \/>\n\t\t\tN\u00e3o, mas j\u00e1 ingeri\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o, nunca ingeri\" for=\"fld_6437431_1_opt2025664\"><input type=\"radio\" id=\"fld_6437431_1_opt2025664\" data-field=\"fld_6437431\" class=\"fld_6437431_1 option-required\" name=\"fld_6437431\" value=\"N\u00e3o, nunca ingeri\"   required=\"required\" data-radio-field=\"fld_6437431_1\" data-type=\"radio\" data-calc-value=\"N\u00e3o, nunca ingeri\" \/>\n\t\t\tN\u00e3o, nunca ingeri\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_950222_1\" data-field-id=\"fld_950222_1\"><div data-field-wrapper=\"fld_950222\" class=\"form-group\" id=\"fld_950222_1-wrap\">\r\n\t<label id=\"fld_950222Label\" for=\"fld_950222_1\" class=\"control-label\">Descreva? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_950222\" value=\"\" data-field=\"fld_950222\" class=\"form-control\" id=\"fld_950222_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_950222Label\" aria-describedby=\"fld_950222Caption\" ><\/textarea>\n\t\t<span id=\"fld_950222Caption\" class=\"help-block\">Qual bebida e quantas doses ou a quanto tempo parou<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1672428\" class=\"form-group\" id=\"fld_1672428_1-wrap\">\r\n\t<label id=\"fld_1672428Label\" for=\"fld_1672428_1\" class=\"control-label\">Descreva seu caf\u00e9 da manh\u00e3 <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1672428\" value=\"\" data-field=\"fld_1672428\" class=\"form-control\" id=\"fld_1672428_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1672428Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1134414\" class=\"form-group\" id=\"fld_1134414_1-wrap\">\r\n\t<label id=\"fld_1134414Label\" for=\"fld_1134414_1\" class=\"control-label\">Descreva seu lanche da manh\u00e3 <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1134414\" value=\"\" data-field=\"fld_1134414\" class=\"form-control\" id=\"fld_1134414_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1134414Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_8285721\" class=\"form-group\" id=\"fld_8285721_1-wrap\">\r\n\t<label id=\"fld_8285721Label\" for=\"fld_8285721_1\" class=\"control-label\">Descreva seu almo\u00e7o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_8285721\" value=\"\" data-field=\"fld_8285721\" class=\"form-control\" id=\"fld_8285721_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_8285721Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6678282\" class=\"form-group\" id=\"fld_6678282_1-wrap\">\r\n\t<label id=\"fld_6678282Label\" for=\"fld_6678282_1\" class=\"control-label\">Descreva seu lanche da tarde <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6678282\" value=\"\" data-field=\"fld_6678282\" class=\"form-control\" id=\"fld_6678282_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6678282Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1152584\" class=\"form-group\" id=\"fld_1152584_1-wrap\">\r\n\t<label id=\"fld_1152584Label\" for=\"fld_1152584_1\" class=\"control-label\">Descreva sua janta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1152584\" value=\"\" data-field=\"fld_1152584\" class=\"form-control\" id=\"fld_1152584_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1152584Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5536810\" class=\"form-group\" id=\"fld_5536810_1-wrap\">\r\n\t<label id=\"fld_5536810Label\" for=\"fld_5536810_1\" class=\"control-label\">Descreva, se possuir, outras refei\u00e7\u00f5es feitas no dia<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5536810\" value=\"\" data-field=\"fld_5536810\" class=\"form-control\" id=\"fld_5536810_1\" rows=\"4\"    aria-labelledby=\"fld_5536810Label\" aria-describedby=\"fld_5536810Caption\" ><\/textarea>\n\t\t<span id=\"fld_5536810Caption\" class=\"help-block\">Refei\u00e7\u00f5es foras as citadas acima<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-22\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5437915\" class=\"form-group\" id=\"fld_5437915_1-wrap\">\r\n\t<label id=\"fld_5437915Label\" for=\"fld_5437915_1\" class=\"control-label\">Voc\u00ea possui algum desejo forte dos seguintes alimentos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1058520\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos a temperatura ambiente\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1058520\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1058520]\"\n                                value=\"Alimentos a temperatura ambiente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos a temperatura ambiente\"\n                            >\n                    Alimentos a temperatura ambiente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1312447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos quentes\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1312447\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1312447]\"\n                                value=\"Alimentos quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos quentes\"\n                            >\n                    Alimentos quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1081833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos frios\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1081833\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1081833]\"\n                                value=\"Alimentos frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos frios\"\n                            >\n                    Alimentos frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1753842\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos gordurosos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1753842\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1753842]\"\n                                value=\"Alimentos gordurosos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos gordurosos\"\n                            >\n                    Alimentos gordurosos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1341831\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos picantes\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1341831\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1341831]\"\n                                value=\"Alimentos picantes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos picantes\"\n                            >\n                    Alimentos picantes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1326130\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos doces\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1326130\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1326130]\"\n                                value=\"Alimentos doces\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos doces\"\n                            >\n                    Alimentos doces                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1338768\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos salgados\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1338768\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1338768]\"\n                                value=\"Alimentos salgados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos salgados\"\n                            >\n                    Alimentos salgados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1694852\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos amargos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1694852\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1694852]\"\n                                value=\"Alimentos amargos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos amargos\"\n                            >\n                    Alimentos amargos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1335845\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos azedos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1335845\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1335845]\"\n                                value=\"Alimentos azedos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Alimentos azedos\"\n                            >\n                    Alimentos azedos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1431473\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Carne\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1431473\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1431473]\"\n                                value=\"Carne\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Carne\"\n                            >\n                    Carne                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1160881\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Peixe\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1160881\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1160881]\"\n                                value=\"Peixe\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Peixe\"\n                            >\n                    Peixe                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1184307\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Ostra\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1184307\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1184307]\"\n                                value=\"Ostra\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Ostra\"\n                            >\n                    Ostra                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1365150\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Ovo\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1365150\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1365150]\"\n                                value=\"Ovo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Ovo\"\n                            >\n                    Ovo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1851586\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Lim\u00e3o\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1851586\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1851586]\"\n                                value=\"Lim\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Lim\u00e3o\"\n                            >\n                    Lim\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1174580\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Frutas\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1174580\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1174580]\"\n                                value=\"Frutas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Frutas\"\n                            >\n                    Frutas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1695553\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Batata\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1695553\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1695553]\"\n                                value=\"Batata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Batata\"\n                            >\n                    Batata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1098491\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Vegetais\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1098491\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1098491]\"\n                                value=\"Vegetais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Vegetais\"\n                            >\n                    Vegetais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1995017\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Picles\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1995017\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1995017]\"\n                                value=\"Picles\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Picles\"\n                            >\n                    Picles                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1154120\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Pipoca\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1154120\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1154120]\"\n                                value=\"Pipoca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Pipoca\"\n                            >\n                    Pipoca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1698403\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"P\u00e3o\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1698403\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1698403]\"\n                                value=\"P\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"P\u00e3o\"\n                            >\n                    P\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1643227\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Pastel\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1643227\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1643227]\"\n                                value=\"Pastel\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Pastel\"\n                            >\n                    Pastel                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1737892\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Queijo\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1737892\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1737892]\"\n                                value=\"Queijo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Queijo\"\n                            >\n                    Queijo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1346776\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Manteiga\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1346776\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1346776]\"\n                                value=\"Manteiga\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Manteiga\"\n                            >\n                    Manteiga                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1271121\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Sorvete\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1271121\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1271121]\"\n                                value=\"Sorvete\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Sorvete\"\n                            >\n                    Sorvete                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1836866\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Chocolate\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1836866\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1836866]\"\n                                value=\"Chocolate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Chocolate\"\n                            >\n                    Chocolate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1554586\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Leite\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1554586\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1554586]\"\n                                value=\"Leite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Leite\"\n                            >\n                    Leite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1418998\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Ch\u00e1\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1418998\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1418998]\"\n                                value=\"Ch\u00e1\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Ch\u00e1\"\n                            >\n                    Ch\u00e1                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1140161\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Cerveja\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1140161\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1140161]\"\n                                value=\"Cerveja\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Cerveja\"\n                            >\n                    Cerveja                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt2032920\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Vinho\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt2032920\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt2032920]\"\n                                value=\"Vinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Vinho\"\n                            >\n                    Vinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt1999316\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Bebidas destiladas\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt1999316\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt1999316]\"\n                                value=\"Bebidas destiladas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Bebidas destiladas\"\n                            >\n                    Bebidas destiladas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_1_opt2005536\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_1\" data-parsley-multiple=\"fld_5437915_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_1_opt2005536\"\n                                class=\"fld_5437915_1 option-required\"\n                                name=\"fld_5437915[opt2005536]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_8312371_1\" data-field-id=\"fld_8312371_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2165263\" class=\"form-group\" id=\"fld_2165263_1-wrap\">\r\n\t<label id=\"fld_2165263Label\" for=\"fld_2165263_1\" class=\"control-label\">Possui algum transtorno alimentar com: <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1079775\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1079775\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1079775]\"\n                                value=\"Alimentos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Alimentos\"\n                            >\n                    Alimentos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1351504\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Carne de gado\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1351504\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1351504]\"\n                                value=\"Carne de gado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Carne de gado\"\n                            >\n                    Carne de gado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1852419\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Carne de porco\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1852419\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1852419]\"\n                                value=\"Carne de porco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Carne de porco\"\n                            >\n                    Carne de porco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1186436\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Aves\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1186436\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1186436]\"\n                                value=\"Aves\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Aves\"\n                            >\n                    Aves                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1501071\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Peixes\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1501071\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1501071]\"\n                                value=\"Peixes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Peixes\"\n                            >\n                    Peixes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1719938\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Marisco\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1719938\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1719938]\"\n                                value=\"Marisco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Marisco\"\n                            >\n                    Marisco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1229162\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"\u00c1gua\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1229162\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1229162]\"\n                                value=\"\u00c1gua\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"\u00c1gua\"\n                            >\n                    \u00c1gua                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt2073242\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Sopa\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt2073242\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt2073242]\"\n                                value=\"Sopa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Sopa\"\n                            >\n                    Sopa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1593151\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Leite\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1593151\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1593151]\"\n                                value=\"Leite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Leite\"\n                            >\n                    Leite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1588801\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"P\u00e3o\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1588801\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1588801]\"\n                                value=\"P\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"P\u00e3o\"\n                            >\n                    P\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1458687\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Ovo\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1458687\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1458687]\"\n                                value=\"Ovo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Ovo\"\n                            >\n                    Ovo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt2064604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Picles\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt2064604\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt2064604]\"\n                                value=\"Picles\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Picles\"\n                            >\n                    Picles                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1527337\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Feij\u00e3o\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1527337\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1527337]\"\n                                value=\"Feij\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Feij\u00e3o\"\n                            >\n                    Feij\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1838213\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Cebola\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1838213\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1838213]\"\n                                value=\"Cebola\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Cebola\"\n                            >\n                    Cebola                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1855152\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Repolho\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1855152\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1855152]\"\n                                value=\"Repolho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Repolho\"\n                            >\n                    Repolho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1701963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Batata\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1701963\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1701963]\"\n                                value=\"Batata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Batata\"\n                            >\n                    Batata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1641802\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Tomate\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1641802\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1641802]\"\n                                value=\"Tomate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Tomate\"\n                            >\n                    Tomate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1831533\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Vegetais\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1831533\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1831533]\"\n                                value=\"Vegetais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Vegetais\"\n                            >\n                    Vegetais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1882780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Sorvete\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1882780\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1882780]\"\n                                value=\"Sorvete\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Sorvete\"\n                            >\n                    Sorvete                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1117488\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos frios\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1117488\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1117488]\"\n                                value=\"Alimentos frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Alimentos frios\"\n                            >\n                    Alimentos frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1934126\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos quentes\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1934126\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1934126]\"\n                                value=\"Alimentos quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Alimentos quentes\"\n                            >\n                    Alimentos quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1203929\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Alimentos azedos\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1203929\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1203929]\"\n                                value=\"Alimentos azedos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Alimentos azedos\"\n                            >\n                    Alimentos azedos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1597126\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1597126\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1597126]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_1_opt1822053\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_1\" data-parsley-multiple=\"fld_2165263_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_1_opt1822053\"\n                                class=\"fld_2165263_1 option-required\"\n                                name=\"fld_2165263[opt1822053]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_804883_1\" data-field-id=\"fld_804883_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-23\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_3091293\" class=\"form-group\" id=\"fld_3091293_1-wrap\">\r\n\t<label id=\"fld_3091293Label\" for=\"fld_3091293_1\" class=\"control-label\">Que tipo de sede voc\u00ea tem? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt2070868\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Pequenas quantidades\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt2070868\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt2070868]\"\n                                value=\"Pequenas quantidades\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Pequenas quantidades\"\n                            >\n                    Pequenas quantidades                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt1926880\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Grandes quantidades\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt1926880\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt1926880]\"\n                                value=\"Grandes quantidades\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Grandes quantidades\"\n                            >\n                    Grandes quantidades                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt1824128\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Bebidas frias\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt1824128\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt1824128]\"\n                                value=\"Bebidas frias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Bebidas frias\"\n                            >\n                    Bebidas frias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt1903840\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Bebidas quentes\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt1903840\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt1903840]\"\n                                value=\"Bebidas quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Bebidas quentes\"\n                            >\n                    Bebidas quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt1924478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Bebidas \u00e0 temperatura ambiente\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt1924478\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt1924478]\"\n                                value=\"Bebidas \u00e0 temperatura ambiente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Bebidas \u00e0 temperatura ambiente\"\n                            >\n                    Bebidas \u00e0 temperatura ambiente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt2023377\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Gelo ou \u00e1gua gelada\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt2023377\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt2023377]\"\n                                value=\"Gelo ou \u00e1gua gelada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Gelo ou \u00e1gua gelada\"\n                            >\n                    Gelo ou \u00e1gua gelada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_1_opt1688907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_1\" data-parsley-multiple=\"fld_3091293_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_1_opt1688907\"\n                                class=\"fld_3091293_1 option-required\"\n                                name=\"fld_3091293[opt1688907]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_821839_1\" data-field-id=\"fld_821839_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-24\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_278843\" class=\"form-group\" id=\"fld_278843_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_278843\" id=\"fld_278843_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_278843\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_278843\" id=\"fld_278843_1_btn\" value=\"\" data-field=\"fld_278843\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_744392\" class=\"form-group\" id=\"fld_744392_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_744392\" id=\"fld_744392_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_744392\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_744392\" id=\"fld_744392_1_btn\" value=\"\" data-field=\"fld_744392\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_962626\" class=\"form-group\" id=\"fld_962626_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_962626\" id=\"fld_962626_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_962626\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_962626\" id=\"fld_962626_1_btn\" value=\"\" data-field=\"fld_962626\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_6\" data-formpage=\"6\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_6\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-25\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8644297\" class=\"form-group\" id=\"fld_8644297_1-wrap\">\r\n\t<label id=\"fld_8644297Label\" for=\"fld_8644297_1\" class=\"control-label\">Voc\u00ea ou algum familiar \u00e9 portador de HIV\/AIDS? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1402298\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1487186\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1659832\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1702867\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1192255\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1407122\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt2029916\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1533618\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_1\" data-parsley-multiple=\"fld_8644297_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_1_opt1180673\"\n                                class=\"fld_8644297_1 option-required\"\n                                name=\"fld_8644297[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1535034\" class=\"form-group\" id=\"fld_1535034_1-wrap\">\r\n\t<label id=\"fld_1535034Label\" for=\"fld_1535034_1\" class=\"control-label\">Voc\u00ea ou algum familiar tem depend\u00eancia de \u00e1lcool? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1402298\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1487186\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1659832\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1702867\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1192255\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1407122\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt2029916\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1533618\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_1\" data-parsley-multiple=\"fld_1535034_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_1_opt1180673\"\n                                class=\"fld_1535034_1 option-required\"\n                                name=\"fld_1535034[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-26\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_739625\" class=\"form-group\" id=\"fld_739625_1-wrap\">\r\n\t<label id=\"fld_739625Label\" for=\"fld_739625_1\" class=\"control-label\">Voc\u00ea ou algum familiar possui alergia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1402298\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1487186\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1659832\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1702867\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1192255\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1407122\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt2029916\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1533618\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_1\" data-parsley-multiple=\"fld_739625_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_1_opt1180673\"\n                                class=\"fld_739625_1 option-required\"\n                                name=\"fld_739625[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_7819773\" class=\"form-group\" id=\"fld_7819773_1-wrap\">\r\n\t<label id=\"fld_7819773Label\" for=\"fld_7819773_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de alzheimer? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1402298\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1487186\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1659832\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1702867\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1192255\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1407122\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt2029916\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1533618\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_1\" data-parsley-multiple=\"fld_7819773_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_1_opt1180673\"\n                                class=\"fld_7819773_1 option-required\"\n                                name=\"fld_7819773[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-27\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7124119\" class=\"form-group\" id=\"fld_7124119_1-wrap\">\r\n\t<label id=\"fld_7124119Label\" for=\"fld_7124119_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de anemia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1402298\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1487186\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1659832\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1702867\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1192255\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1407122\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt2029916\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1533618\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_1\" data-parsley-multiple=\"fld_7124119_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_1_opt1180673\"\n                                class=\"fld_7124119_1 option-required\"\n                                name=\"fld_7124119[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5003379\" class=\"form-group\" id=\"fld_5003379_1-wrap\">\r\n\t<label id=\"fld_5003379Label\" for=\"fld_5003379_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de anemia falciforme? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1402298\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1487186\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1659832\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1702867\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1192255\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1407122\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt2029916\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1533618\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_1\" data-parsley-multiple=\"fld_5003379_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_1_opt1180673\"\n                                class=\"fld_5003379_1 option-required\"\n                                name=\"fld_5003379[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-28\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4726702\" class=\"form-group\" id=\"fld_4726702_1-wrap\">\r\n\t<label id=\"fld_4726702Label\" for=\"fld_4726702_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de artrite? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1402298\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1487186\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1659832\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1702867\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1192255\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1407122\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt2029916\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1533618\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_1\" data-parsley-multiple=\"fld_4726702_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_1_opt1180673\"\n                                class=\"fld_4726702_1 option-required\"\n                                name=\"fld_4726702[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2372214\" class=\"form-group\" id=\"fld_2372214_1-wrap\">\r\n\t<label id=\"fld_2372214Label\" for=\"fld_2372214_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de asma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1402298\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1487186\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1659832\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1702867\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1192255\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1407122\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt2029916\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1533618\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_1\" data-parsley-multiple=\"fld_2372214_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_1_opt1180673\"\n                                class=\"fld_2372214_1 option-required\"\n                                name=\"fld_2372214[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-29\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_9253278\" class=\"form-group\" id=\"fld_9253278_1-wrap\">\r\n\t<label id=\"fld_9253278Label\" for=\"fld_9253278_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de defeitos de nascen\u00e7a? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1402298\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1487186\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1659832\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1702867\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1192255\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1407122\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt2029916\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1533618\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_1\" data-parsley-multiple=\"fld_9253278_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_1_opt1180673\"\n                                class=\"fld_9253278_1 option-required\"\n                                name=\"fld_9253278[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2941180\" class=\"form-group\" id=\"fld_2941180_1-wrap\">\r\n\t<label id=\"fld_2941180Label\" for=\"fld_2941180_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de dist\u00farbio hemorr\u00e1gico? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1402298\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1487186\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1659832\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1702867\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1192255\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1407122\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt2029916\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1533618\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_1\" data-parsley-multiple=\"fld_2941180_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_1_opt1180673\"\n                                class=\"fld_2941180_1 option-required\"\n                                name=\"fld_2941180[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-30\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2987199\" class=\"form-group\" id=\"fld_2987199_1-wrap\">\r\n\t<label id=\"fld_2987199Label\" for=\"fld_2987199_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1402298\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1487186\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1659832\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1702867\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1192255\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1407122\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt2029916\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1533618\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_1\" data-parsley-multiple=\"fld_2987199_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_1_opt1180673\"\n                                class=\"fld_2987199_1 option-required\"\n                                name=\"fld_2987199[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5834546\" class=\"form-group\" id=\"fld_5834546_1-wrap\">\r\n\t<label id=\"fld_5834546Label\" for=\"fld_5834546_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer de mama? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1402298\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1487186\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1659832\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1702867\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1192255\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1407122\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt2029916\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1533618\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_1\" data-parsley-multiple=\"fld_5834546_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_1_opt1180673\"\n                                class=\"fld_5834546_1 option-required\"\n                                name=\"fld_5834546[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-31\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2091625\" class=\"form-group\" id=\"fld_2091625_1-wrap\">\r\n\t<label id=\"fld_2091625Label\" for=\"fld_2091625_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer de pr\u00f3stata? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1402298\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1487186\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1659832\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1702867\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1192255\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1407122\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt2029916\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1533618\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_1\" data-parsley-multiple=\"fld_2091625_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_1_opt1180673\"\n                                class=\"fld_2091625_1 option-required\"\n                                name=\"fld_2091625[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2327864\" class=\"form-group\" id=\"fld_2327864_1-wrap\">\r\n\t<label id=\"fld_2327864Label\" for=\"fld_2327864_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de depress\u00e3o? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1402298\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1487186\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1659832\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1702867\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1192255\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1407122\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt2029916\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1533618\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_1\" data-parsley-multiple=\"fld_2327864_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_1_opt1180673\"\n                                class=\"fld_2327864_1 option-required\"\n                                name=\"fld_2327864[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-32\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4341577\" class=\"form-group\" id=\"fld_4341577_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_4341577\" id=\"fld_4341577_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_4341577\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_4341577\" id=\"fld_4341577_1_btn\" value=\"\" data-field=\"fld_4341577\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3822246\" class=\"form-group\" id=\"fld_3822246_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_3822246\" id=\"fld_3822246_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_3822246\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_3822246\" id=\"fld_3822246_1_btn\" value=\"\" data-field=\"fld_3822246\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_7588033\" class=\"form-group\" id=\"fld_7588033_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_7588033\" id=\"fld_7588033_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_7588033\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_7588033\" id=\"fld_7588033_1_btn\" value=\"\" data-field=\"fld_7588033\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_7\" data-formpage=\"7\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_7\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-33\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6756990\" class=\"form-group\" id=\"fld_6756990_1-wrap\">\r\n\t<label id=\"fld_6756990Label\" for=\"fld_6756990_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de diabetes? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1402298\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1487186\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1659832\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1702867\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1192255\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1407122\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt2029916\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1533618\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_1\" data-parsley-multiple=\"fld_6756990_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_1_opt1180673\"\n                                class=\"fld_6756990_1 option-required\"\n                                name=\"fld_6756990[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2505830\" class=\"form-group\" id=\"fld_2505830_1-wrap\">\r\n\t<label id=\"fld_2505830Label\" for=\"fld_2505830_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de enfisema? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1402298\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1487186\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1659832\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1702867\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1192255\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1407122\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt2029916\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1533618\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_1\" data-parsley-multiple=\"fld_2505830_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_1_opt1180673\"\n                                class=\"fld_2505830_1 option-required\"\n                                name=\"fld_2505830[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-34\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2805064\" class=\"form-group\" id=\"fld_2805064_1-wrap\">\r\n\t<label id=\"fld_2805064Label\" for=\"fld_2805064_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de epilepsia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1402298\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1487186\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1659832\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1702867\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1192255\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1407122\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt2029916\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1533618\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_1\" data-parsley-multiple=\"fld_2805064_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_1_opt1180673\"\n                                class=\"fld_2805064_1 option-required\"\n                                name=\"fld_2805064[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_4444936\" class=\"form-group\" id=\"fld_4444936_1-wrap\">\r\n\t<label id=\"fld_4444936Label\" for=\"fld_4444936_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de glaucoma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1402298\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1487186\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1659832\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1702867\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1192255\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1407122\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt2029916\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1533618\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_1\" data-parsley-multiple=\"fld_4444936_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_1_opt1180673\"\n                                class=\"fld_4444936_1 option-required\"\n                                name=\"fld_4444936[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-35\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4453698\" class=\"form-group\" id=\"fld_4453698_1-wrap\">\r\n\t<label id=\"fld_4453698Label\" for=\"fld_4453698_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de problemas card\u00edacos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1402298\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1487186\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1659832\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1702867\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1192255\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1407122\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt2029916\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1533618\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_1\" data-parsley-multiple=\"fld_4453698_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_1_opt1180673\"\n                                class=\"fld_4453698_1 option-required\"\n                                name=\"fld_4453698[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1629592\" class=\"form-group\" id=\"fld_1629592_1-wrap\">\r\n\t<label id=\"fld_1629592Label\" for=\"fld_1629592_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu ataque card\u00edaco? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1402298\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1487186\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1659832\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1702867\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1192255\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1407122\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt2029916\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1533618\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_1\" data-parsley-multiple=\"fld_1629592_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_1_opt1180673\"\n                                class=\"fld_1629592_1 option-required\"\n                                name=\"fld_1629592[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-36\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5725260\" class=\"form-group\" id=\"fld_5725260_1-wrap\">\r\n\t<label id=\"fld_5725260Label\" for=\"fld_5725260_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de press\u00e3o alta? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1402298\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1487186\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1659832\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1702867\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1192255\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1407122\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt2029916\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1533618\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_1\" data-parsley-multiple=\"fld_5725260_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_1_opt1180673\"\n                                class=\"fld_5725260_1 option-required\"\n                                name=\"fld_5725260[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_224243\" class=\"form-group\" id=\"fld_224243_1-wrap\">\r\n\t<label id=\"fld_224243Label\" for=\"fld_224243_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a renal? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1402298\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1487186\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1659832\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1702867\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1192255\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1407122\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt2029916\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1533618\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_1\" data-parsley-multiple=\"fld_224243_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_1_opt1180673\"\n                                class=\"fld_224243_1 option-required\"\n                                name=\"fld_224243[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-37\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4062738\" class=\"form-group\" id=\"fld_4062738_1-wrap\">\r\n\t<label id=\"fld_4062738Label\" for=\"fld_4062738_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a hep\u00e1tica? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1402298\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1487186\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1659832\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1702867\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1192255\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1407122\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt2029916\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1533618\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_1\" data-parsley-multiple=\"fld_4062738_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_1_opt1180673\"\n                                class=\"fld_4062738_1 option-required\"\n                                name=\"fld_4062738[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2448871\" class=\"form-group\" id=\"fld_2448871_1-wrap\">\r\n\t<label id=\"fld_2448871Label\" for=\"fld_2448871_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de enxaquecas ou dores de cabe\u00e7a constantes? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1402298\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1487186\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1659832\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1702867\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1192255\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1407122\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt2029916\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1533618\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_1\" data-parsley-multiple=\"fld_2448871_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_1_opt1180673\"\n                                class=\"fld_2448871_1 option-required\"\n                                name=\"fld_2448871[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-38\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_3989334\" class=\"form-group\" id=\"fld_3989334_1-wrap\">\r\n\t<label id=\"fld_3989334Label\" for=\"fld_3989334_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a mental? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1402298\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1487186\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1659832\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1702867\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1192255\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1407122\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt2029916\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1533618\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_1\" data-parsley-multiple=\"fld_3989334_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_1_opt1180673\"\n                                class=\"fld_3989334_1 option-required\"\n                                name=\"fld_3989334[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6403231\" class=\"form-group\" id=\"fld_6403231_1-wrap\">\r\n\t<label id=\"fld_6403231Label\" for=\"fld_6403231_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu de pneumonia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1402298\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1487186\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1659832\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1702867\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1192255\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1407122\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt2029916\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1533618\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_1\" data-parsley-multiple=\"fld_6403231_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_1_opt1180673\"\n                                class=\"fld_6403231_1 option-required\"\n                                name=\"fld_6403231[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-39\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4249673\" class=\"form-group\" id=\"fld_4249673_1-wrap\">\r\n\t<label id=\"fld_4249673Label\" for=\"fld_4249673_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de tuberculose? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1402298\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1487186\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1659832\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1702867\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1192255\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1407122\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt2029916\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1533618\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_1\" data-parsley-multiple=\"fld_4249673_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_1_opt1180673\"\n                                class=\"fld_4249673_1 option-required\"\n                                name=\"fld_4249673[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6750828\" class=\"form-group\" id=\"fld_6750828_1-wrap\">\r\n\t<label id=\"fld_6750828Label\" for=\"fld_6750828_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu acidente vascular cerebral? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1402298\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1487186\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1659832\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1702867\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1192255\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1407122\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt2029916\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1533618\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_1\" data-parsley-multiple=\"fld_6750828_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_1_opt1180673\"\n                                class=\"fld_6750828_1 option-required\"\n                                name=\"fld_6750828[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-40\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5282480\" class=\"form-group\" id=\"fld_5282480_1-wrap\">\r\n\t<label id=\"fld_5282480Label\" for=\"fld_5282480_1\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de \u00falceras? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1402298\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1487186\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1659832\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1702867\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1192255\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1407122\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt2029916\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1533618\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_1\" data-parsley-multiple=\"fld_5282480_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_1_opt1180673\"\n                                class=\"fld_5282480_1 option-required\"\n                                name=\"fld_5282480[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2861783\" class=\"form-group\" id=\"fld_2861783_1-wrap\">\r\n\t<label id=\"fld_2861783Label\" for=\"fld_2861783_1\" class=\"control-label\">Voc\u00ea ou algum familiar tentou ou praticou suic\u00eddio? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1402298\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1487186\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1659832\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1702867\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1192255\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1407122\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt2029916\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1533618\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_1_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_1\" data-parsley-multiple=\"fld_2861783_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_1_opt1180673\"\n                                class=\"fld_2861783_1 option-required\"\n                                name=\"fld_2861783[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_1\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-41\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_543737\" class=\"form-group\" id=\"fld_543737_1-wrap\">\r\n\t<label id=\"fld_543737Label\" for=\"fld_543737_1\" class=\"control-label\">Alguma outra doen\u00e7a relevante em algum familiar?<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_543737\" value=\"\" data-field=\"fld_543737\" class=\"form-control\" id=\"fld_543737_1\" rows=\"4\"    aria-labelledby=\"fld_543737Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-42\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_2697902\" class=\"form-group\" id=\"fld_2697902_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_2697902\" id=\"fld_2697902_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_2697902\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_2697902\" id=\"fld_2697902_1_btn\" value=\"\" data-field=\"fld_2697902\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_7233284\" class=\"form-group\" id=\"fld_7233284_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_7233284\" id=\"fld_7233284_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_7233284\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_7233284\" id=\"fld_7233284_1_btn\" value=\"\" data-field=\"fld_7233284\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_1805497\" class=\"form-group\" id=\"fld_1805497_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_1805497\" id=\"fld_1805497_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_1805497\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_1805497\" id=\"fld_1805497_1_btn\" value=\"\" data-field=\"fld_1805497\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_8\" data-formpage=\"8\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_8\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-43\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8297592\" class=\"form-group\" id=\"fld_8297592_1-wrap\">\r\n\t<label id=\"fld_8297592Label\" for=\"fld_8297592_1\" class=\"control-label\">Cardiovascular <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1841171\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Press\u00e3o arterial alta\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1841171\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1841171]\"\n                                value=\"Press\u00e3o arterial alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Press\u00e3o arterial alta\"\n                            >\n                    Press\u00e3o arterial alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1058545\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Press\u00e3o arterial baixa\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1058545\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1058545]\"\n                                value=\"Press\u00e3o arterial baixa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Press\u00e3o arterial baixa\"\n                            >\n                    Press\u00e3o arterial baixa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt2060889\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Dor no t\u00f3rax do lado esquerdo\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt2060889\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt2060889]\"\n                                value=\"Dor no t\u00f3rax do lado esquerdo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Dor no t\u00f3rax do lado esquerdo\"\n                            >\n                    Dor no t\u00f3rax do lado esquerdo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1328748\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e1 circula\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1328748\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1328748]\"\n                                value=\"M\u00e1 circula\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"M\u00e1 circula\u00e7\u00e3o\"\n                            >\n                    M\u00e1 circula\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt2018373\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt2018373\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt2018373]\"\n                                value=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                            >\n                    Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1390552\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Palpita\u00e7\u00f5es cardiacas\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1390552\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1390552]\"\n                                value=\"Palpita\u00e7\u00f5es cardiacas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Palpita\u00e7\u00f5es cardiacas\"\n                            >\n                    Palpita\u00e7\u00f5es cardiacas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1143912\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1143912\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1143912]\"\n                                value=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                            >\n                    Constri\u00e7\u00e3o do cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1336817\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1336817\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1336817]\"\n                                value=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                            >\n                    Dilata\u00e7\u00e3o do cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1637625\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Palpita\u00e7\u00f5es cardiacas\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1637625\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1637625]\"\n                                value=\"Palpita\u00e7\u00f5es cardiacas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Palpita\u00e7\u00f5es cardiacas\"\n                            >\n                    Palpita\u00e7\u00f5es cardiacas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1183665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1183665\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1183665]\"\n                                value=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                            >\n                    Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1388785\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Acidente vascular cerebral\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1388785\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1388785]\"\n                                value=\"Acidente vascular cerebral\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Acidente vascular cerebral\"\n                            >\n                    Acidente vascular cerebral                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1063189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3os e\/ou p\u00e9s frios\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1063189\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1063189]\"\n                                value=\"M\u00e3os e\/ou p\u00e9s frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"M\u00e3os e\/ou p\u00e9s frios\"\n                            >\n                    M\u00e3os e\/ou p\u00e9s frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1347171\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Colesterol elevado\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1347171\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1347171]\"\n                                value=\"Colesterol elevado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Colesterol elevado\"\n                            >\n                    Colesterol elevado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1225900\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Colesterol bom baixo (HDL)\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1225900\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1225900]\"\n                                value=\"Colesterol bom baixo (HDL)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Colesterol bom baixo (HDL)\"\n                            >\n                    Colesterol bom baixo (HDL)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1883518\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Co\u00e1gulos sangu\u00edneos\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1883518\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1883518]\"\n                                value=\"Co\u00e1gulos sangu\u00edneos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Co\u00e1gulos sangu\u00edneos\"\n                            >\n                    Co\u00e1gulos sangu\u00edneos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1642685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1642685\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1642685]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_1_opt1542870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_1\" data-parsley-multiple=\"fld_8297592_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_1_opt1542870\"\n                                class=\"fld_8297592_1 option-required\"\n                                name=\"fld_8297592[opt1542870]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3571860_1\" data-field-id=\"fld_3571860_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_8430632\" class=\"form-group\" id=\"fld_8430632_1-wrap\">\r\n\t<label id=\"fld_8430632Label\" for=\"fld_8430632_1\" class=\"control-label\">Respirat\u00f3rio <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1600203\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o irregular\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1600203\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1600203]\"\n                                value=\"Respira\u00e7\u00e3o irregular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o irregular\"\n                            >\n                    Respira\u00e7\u00e3o irregular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1128382\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o lenta\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1128382\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1128382]\"\n                                value=\"Respira\u00e7\u00e3o lenta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o lenta\"\n                            >\n                    Respira\u00e7\u00e3o lenta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1727204\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o acelerada\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1727204\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1727204]\"\n                                value=\"Respira\u00e7\u00e3o acelerada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o acelerada\"\n                            >\n                    Respira\u00e7\u00e3o acelerada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1132491\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o profunda\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1132491\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1132491]\"\n                                value=\"Respira\u00e7\u00e3o profunda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o profunda\"\n                            >\n                    Respira\u00e7\u00e3o profunda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1066158\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1066158\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1066158]\"\n                                value=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                            >\n                    Respira\u00e7\u00e3o obstru\u00edda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1222215\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o fraca\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1222215\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1222215]\"\n                                value=\"Respira\u00e7\u00e3o fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o fraca\"\n                            >\n                    Respira\u00e7\u00e3o fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1532189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o com chiado\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1532189\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1532189]\"\n                                value=\"Respira\u00e7\u00e3o com chiado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o com chiado\"\n                            >\n                    Respira\u00e7\u00e3o com chiado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1096865\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Chocalhar no peito\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1096865\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1096865]\"\n                                value=\"Chocalhar no peito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Chocalhar no peito\"\n                            >\n                    Chocalhar no peito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1990444\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade respirat\u00f3ria\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1990444\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1990444]\"\n                                value=\"Dificuldade respirat\u00f3ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Dificuldade respirat\u00f3ria\"\n                            >\n                    Dificuldade respirat\u00f3ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1980315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Falta de ar\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1980315\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1980315]\"\n                                value=\"Falta de ar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Falta de ar\"\n                            >\n                    Falta de ar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1091923\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Enfisema pulmonar\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1091923\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1091923]\"\n                                value=\"Enfisema pulmonar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Enfisema pulmonar\"\n                            >\n                    Enfisema pulmonar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1084059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Asfixia\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1084059\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1084059]\"\n                                value=\"Asfixia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Asfixia\"\n                            >\n                    Asfixia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1817760\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Tosse persistente\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1817760\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1817760]\"\n                                value=\"Tosse persistente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Tosse persistente\"\n                            >\n                    Tosse persistente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1178422\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Alergia a p\u00f3\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1178422\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1178422]\"\n                                value=\"Alergia a p\u00f3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Alergia a p\u00f3\"\n                            >\n                    Alergia a p\u00f3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1962993\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Ataques de asma\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1962993\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1962993]\"\n                                value=\"Ataques de asma\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Ataques de asma\"\n                            >\n                    Ataques de asma                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt2090341\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Secre\u00e7\u00e3o nasal\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt2090341\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt2090341]\"\n                                value=\"Secre\u00e7\u00e3o nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Secre\u00e7\u00e3o nasal\"\n                            >\n                    Secre\u00e7\u00e3o nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1230451\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Congest\u00e3o nasal\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1230451\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1230451]\"\n                                value=\"Congest\u00e3o nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Congest\u00e3o nasal\"\n                            >\n                    Congest\u00e3o nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1631590\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Sinusite\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1631590\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1631590]\"\n                                value=\"Sinusite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Sinusite\"\n                            >\n                    Sinusite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1256125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1256125\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1256125]\"\n                                value=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                            >\n                    Infec\u00e7\u00f5es respirat\u00f3rias frequentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1310217\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Dor de garganta\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1310217\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1310217]\"\n                                value=\"Dor de garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Dor de garganta\"\n                            >\n                    Dor de garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1352673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Gripe\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1352673\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1352673]\"\n                                value=\"Gripe\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Gripe\"\n                            >\n                    Gripe                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1308142\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Escarro amarelo\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1308142\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1308142]\"\n                                value=\"Escarro amarelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Escarro amarelo\"\n                            >\n                    Escarro amarelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1198987\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Escarro verde\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1198987\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1198987]\"\n                                value=\"Escarro verde\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Escarro verde\"\n                            >\n                    Escarro verde                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1193701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Escarro preto\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1193701\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1193701]\"\n                                value=\"Escarro preto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Escarro preto\"\n                            >\n                    Escarro preto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt1867149\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Escarro com sangue\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt1867149\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt1867149]\"\n                                value=\"Escarro com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Escarro com sangue\"\n                            >\n                    Escarro com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt2003271\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt2003271\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt2003271]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_1_opt2012644\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_1\" data-parsley-multiple=\"fld_8430632_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_1_opt2012644\"\n                                class=\"fld_8430632_1 option-required\"\n                                name=\"fld_8430632[opt2012644]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6470066_1\" data-field-id=\"fld_6470066_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-44\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5600968\" class=\"form-group\" id=\"fld_5600968_1-wrap\">\r\n\t<label id=\"fld_5600968Label\" for=\"fld_5600968_1\" class=\"control-label\">Gastrointestinal <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1130273\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Arroto\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1130273\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1130273]\"\n                                value=\"Arroto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Arroto\"\n                            >\n                    Arroto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1214617\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Mau h\u00e1lito\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1214617\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1214617]\"\n                                value=\"Mau h\u00e1lito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Mau h\u00e1lito\"\n                            >\n                    Mau h\u00e1lito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1490099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Azia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1490099\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1490099]\"\n                                value=\"Azia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Azia\"\n                            >\n                    Azia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1958302\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1usea\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1958302\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1958302]\"\n                                value=\"N\u00e1usea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"N\u00e1usea\"\n                            >\n                    N\u00e1usea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1268630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Indigest\u00e3o\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1268630\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1268630]\"\n                                value=\"Indigest\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Indigest\u00e3o\"\n                            >\n                    Indigest\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1115122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Plenitude\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1115122\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1115122]\"\n                                value=\"Plenitude\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Plenitude\"\n                            >\n                    Plenitude                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1856349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1856349\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1856349]\"\n                                value=\"Incha\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Incha\u00e7o\"\n                            >\n                    Incha\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1359453\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1359453\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1359453]\"\n                                value=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                            >\n                    Sensa\u00e7\u00e3o de vazio no est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1352789\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Peso no est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1352789\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1352789]\"\n                                value=\"Peso no est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Peso no est\u00f4mago\"\n                            >\n                    Peso no est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1508596\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"V\u00f4mitos\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1508596\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1508596]\"\n                                value=\"V\u00f4mitos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"V\u00f4mitos\"\n                            >\n                    V\u00f4mitos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1633924\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Dor abdominal\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1633924\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1633924]\"\n                                value=\"Dor abdominal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Dor abdominal\"\n                            >\n                    Dor abdominal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1558725\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Dor de est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1558725\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1558725]\"\n                                value=\"Dor de est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Dor de est\u00f4mago\"\n                            >\n                    Dor de est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1388446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"H\u00e9rnia de hiato\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1388446\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1388446]\"\n                                value=\"H\u00e9rnia de hiato\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"H\u00e9rnia de hiato\"\n                            >\n                    H\u00e9rnia de hiato                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1353067\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"\u00dalceras estomacais\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1353067\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1353067]\"\n                                value=\"\u00dalceras estomacais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"\u00dalceras estomacais\"\n                            >\n                    \u00dalceras estomacais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1616061\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Problemas de f\u00edgado\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1616061\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1616061]\"\n                                value=\"Problemas de f\u00edgado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Problemas de f\u00edgado\"\n                            >\n                    Problemas de f\u00edgado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1575663\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Hepatite\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1575663\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1575663]\"\n                                value=\"Hepatite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Hepatite\"\n                            >\n                    Hepatite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1978855\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"C\u00e1lculo ou barro biliar\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1978855\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1978855]\"\n                                value=\"C\u00e1lculo ou barro biliar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"C\u00e1lculo ou barro biliar\"\n                            >\n                    C\u00e1lculo ou barro biliar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1700759\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Gases\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1700759\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1700759]\"\n                                value=\"Gases\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Gases\"\n                            >\n                    Gases                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1053833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Flatul\u00eancia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1053833\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1053833]\"\n                                value=\"Flatul\u00eancia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Flatul\u00eancia\"\n                            >\n                    Flatul\u00eancia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1980669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"C\u00f3licas intestinais\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1980669\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1980669]\"\n                                value=\"C\u00f3licas intestinais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"C\u00f3licas intestinais\"\n                            >\n                    C\u00f3licas intestinais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1425904\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Colite\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1425904\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1425904]\"\n                                value=\"Colite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Colite\"\n                            >\n                    Colite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt2067315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Pris\u00e3o de ventre\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt2067315\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt2067315]\"\n                                value=\"Pris\u00e3o de ventre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Pris\u00e3o de ventre\"\n                            >\n                    Pris\u00e3o de ventre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1654550\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1654550\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1654550]\"\n                                value=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                            >\n                    1 \u00e0 2 evacua\u00e7\u00f5es por dia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1673059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1673059\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1673059]\"\n                                value=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                            >\n                    2 ou menos evacua\u00e7\u00f5es por semana                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1404606\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Dor retal\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1404606\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1404606]\"\n                                value=\"Dor retal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Dor retal\"\n                            >\n                    Dor retal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1711979\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Hemorr\u00f3idas\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1711979\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1711979]\"\n                                value=\"Hemorr\u00f3idas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Hemorr\u00f3idas\"\n                            >\n                    Hemorr\u00f3idas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1625351\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Caibras\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1625351\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1625351]\"\n                                value=\"Caibras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Caibras\"\n                            >\n                    Caibras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1158478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Anorexia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1158478\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1158478]\"\n                                value=\"Anorexia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Anorexia\"\n                            >\n                    Anorexia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1095824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Bulimia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1095824\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1095824]\"\n                                value=\"Bulimia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Bulimia\"\n                            >\n                    Bulimia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt2011413\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt2011413\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt2011413]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_1_opt1165916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_1\" data-parsley-multiple=\"fld_5600968_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_1_opt1165916\"\n                                class=\"fld_5600968_1 option-required\"\n                                name=\"fld_5600968[opt1165916]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2917925_1\" data-field-id=\"fld_2917925_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2481233\" class=\"form-group\" id=\"fld_2481233_1-wrap\">\r\n\t<label id=\"fld_2481233Label\" for=\"fld_2481233_1\" class=\"control-label\">Fezes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1474365\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Aguada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1474365\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1474365]\"\n                                value=\"Aguada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Aguada\"\n                            >\n                    Aguada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1237091\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Biliosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1237091\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1237091]\"\n                                value=\"Biliosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Biliosa\"\n                            >\n                    Biliosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1823293\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Diarreica\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1823293\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1823293]\"\n                                value=\"Diarreica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Diarreica\"\n                            >\n                    Diarreica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1462446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Mole\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1462446\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1462446]\"\n                                value=\"Mole\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Mole\"\n                            >\n                    Mole                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1568393\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Seca\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1568393\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1568393]\"\n                                value=\"Seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Seca\"\n                            >\n                    Seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1214726\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Solta\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1214726\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1214726]\"\n                                value=\"Solta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Solta\"\n                            >\n                    Solta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1941003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Volumosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1941003\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1941003]\"\n                                value=\"Volumosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Volumosa\"\n                            >\n                    Volumosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1683204\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Espumosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1683204\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1683204]\"\n                                value=\"Espumosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Espumosa\"\n                            >\n                    Espumosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1906127\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Gordurosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1906127\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1906127]\"\n                                value=\"Gordurosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Gordurosa\"\n                            >\n                    Gordurosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1120921\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Inodora\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1120921\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1120921]\"\n                                value=\"Inodora\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Inodora\"\n                            >\n                    Inodora                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1161657\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"F\u00e9tida\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1161657\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1161657]\"\n                                value=\"F\u00e9tida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"F\u00e9tida\"\n                            >\n                    F\u00e9tida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1921606\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Viscosa ou com muco\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1921606\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1921606]\"\n                                value=\"Viscosa ou com muco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Viscosa ou com muco\"\n                            >\n                    Viscosa ou com muco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1085211\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Sanguinolenta ou com sangue\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1085211\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1085211]\"\n                                value=\"Sanguinolenta ou com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Sanguinolenta ou com sangue\"\n                            >\n                    Sanguinolenta ou com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1805023\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Involunt\u00e1ria\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1805023\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1805023]\"\n                                value=\"Involunt\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Involunt\u00e1ria\"\n                            >\n                    Involunt\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1102273\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Frequente\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1102273\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1102273]\"\n                                value=\"Frequente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Frequente\"\n                            >\n                    Frequente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1055771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Regular\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1055771\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1055771]\"\n                                value=\"Regular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Regular\"\n                            >\n                    Regular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1974156\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Escassa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1974156\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1974156]\"\n                                value=\"Escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Escassa\"\n                            >\n                    Escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1192795\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Dif\u00edcil \"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1192795\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1192795]\"\n                                value=\"Dif\u00edcil \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Dif\u00edcil \"\n                            >\n                    Dif\u00edcil                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1488604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Constipada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1488604\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1488604]\"\n                                value=\"Constipada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Constipada\"\n                            >\n                    Constipada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1467778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1467778\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1467778]\"\n                                value=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                            >\n                    C\u00f3lica antes da evacua\u00e7\u00e3o                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1280283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Dolorosa ao sair\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1280283\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1280283]\"\n                                value=\"Dolorosa ao sair\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Dolorosa ao sair\"\n                            >\n                    Dolorosa ao sair                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1783669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1783669\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1783669]\"\n                                value=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                            >\n                    Desejo sem sucesso de evacua\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt2063580\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt2063580\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt2063580]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1591681\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Formato de bolas\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1591681\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1591681]\"\n                                value=\"Formato de bolas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Formato de bolas\"\n                            >\n                    Formato de bolas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1423962\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Formato estreito\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1423962\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1423962]\"\n                                value=\"Formato estreito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Formato estreito\"\n                            >\n                    Formato estreito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1729824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Formato picado\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1729824\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1729824]\"\n                                value=\"Formato picado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Formato picado\"\n                            >\n                    Formato picado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1705321\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Formato plano\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1705321\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1705321]\"\n                                value=\"Formato plano\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Formato plano\"\n                            >\n                    Formato plano                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1469230\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Formato pastoso\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1469230\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1469230]\"\n                                value=\"Formato pastoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Formato pastoso\"\n                            >\n                    Formato pastoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1197009\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor amarela\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1197009\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1197009]\"\n                                value=\"Cor amarela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor amarela\"\n                            >\n                    Cor amarela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1594334\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor azulada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1594334\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1594334]\"\n                                value=\"Cor azulada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor azulada\"\n                            >\n                    Cor azulada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1690415\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor branca\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1690415\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1690415]\"\n                                value=\"Cor branca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor branca\"\n                            >\n                    Cor branca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1422534\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor cinza\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1422534\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1422534]\"\n                                value=\"Cor cinza\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor cinza\"\n                            >\n                    Cor cinza                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt2025174\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor laranja\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt2025174\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt2025174]\"\n                                value=\"Cor laranja\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor laranja\"\n                            >\n                    Cor laranja                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1171192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor verde\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1171192\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1171192]\"\n                                value=\"Cor verde\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor verde\"\n                            >\n                    Cor verde                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1125149\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor marrom\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1125149\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1125149]\"\n                                value=\"Cor marrom\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor marrom\"\n                            >\n                    Cor marrom                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1106861\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Cor preta\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1106861\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1106861]\"\n                                value=\"Cor preta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Cor preta\"\n                            >\n                    Cor preta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_1_opt1984519\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_1\" data-parsley-multiple=\"fld_2481233_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_1_opt1984519\"\n                                class=\"fld_2481233_1 option-required\"\n                                name=\"fld_2481233[opt1984519]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2304231_1\" data-field-id=\"fld_2304231_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-45\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1996962\" class=\"form-group\" id=\"fld_1996962_1-wrap\">\r\n\t<label id=\"fld_1996962Label\" for=\"fld_1996962_1\" class=\"control-label\">Rins e Vias Urin\u00e1rias <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1691811\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"C\u00edrculos escuros sob os olhos\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1691811\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1691811]\"\n                                value=\"C\u00edrculos escuros sob os olhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"C\u00edrculos escuros sob os olhos\"\n                            >\n                    C\u00edrculos escuros sob os olhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1306639\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Levantar a noite para urinar uma vez\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1306639\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1306639]\"\n                                value=\"Levantar a noite para urinar uma vez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Levantar a noite para urinar uma vez\"\n                            >\n                    Levantar a noite para urinar uma vez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1326262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Levantar a noite para urinar mais de uma vez\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1326262\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1326262]\"\n                                value=\"Levantar a noite para urinar mais de uma vez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Levantar a noite para urinar mais de uma vez\"\n                            >\n                    Levantar a noite para urinar mais de uma vez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1533939\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1533939\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1533939]\"\n                                value=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                            >\n                    Reten\u00e7\u00e3o de l\u00edquidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1800596\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o abundante\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1800596\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1800596]\"\n                                value=\"Mic\u00e7\u00e3o abundante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o abundante\"\n                            >\n                    Mic\u00e7\u00e3o abundante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1593350\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o escassa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1593350\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1593350]\"\n                                value=\"Mic\u00e7\u00e3o escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o escassa\"\n                            >\n                    Mic\u00e7\u00e3o escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1325615\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o excessiva\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1325615\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1325615]\"\n                                value=\"Mic\u00e7\u00e3o excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o excessiva\"\n                            >\n                    Mic\u00e7\u00e3o excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt2039729\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt2039729\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt2039729]\"\n                                value=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                            >\n                    Mic\u00e7\u00e3o involunt\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1266565\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o dolorosa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1266565\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1266565]\"\n                                value=\"Mic\u00e7\u00e3o dolorosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o dolorosa\"\n                            >\n                    Mic\u00e7\u00e3o dolorosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1095793\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1095793\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1095793]\"\n                                value=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                            >\n                    Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1647703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o dificultosa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1647703\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1647703]\"\n                                value=\"Mic\u00e7\u00e3o dificultosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o dificultosa\"\n                            >\n                    Mic\u00e7\u00e3o dificultosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1560233\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o retardada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1560233\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1560233]\"\n                                value=\"Mic\u00e7\u00e3o retardada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o retardada\"\n                            >\n                    Mic\u00e7\u00e3o retardada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1497493\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o interrompida\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1497493\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1497493]\"\n                                value=\"Mic\u00e7\u00e3o interrompida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o interrompida\"\n                            >\n                    Mic\u00e7\u00e3o interrompida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1139652\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o em gotas\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1139652\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1139652]\"\n                                value=\"Mic\u00e7\u00e3o em gotas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o em gotas\"\n                            >\n                    Mic\u00e7\u00e3o em gotas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1502833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1502833\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1502833]\"\n                                value=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                            >\n                    Mic\u00e7\u00e3o obstru\u00edda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt2077418\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Reten\u00e7\u00e3o de urina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt2077418\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt2077418]\"\n                                value=\"Reten\u00e7\u00e3o de urina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Reten\u00e7\u00e3o de urina\"\n                            >\n                    Reten\u00e7\u00e3o de urina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1448753\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Paralisia de urina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1448753\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1448753]\"\n                                value=\"Paralisia de urina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Paralisia de urina\"\n                            >\n                    Paralisia de urina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1316800\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Pedras nos rins\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1316800\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1316800]\"\n                                value=\"Pedras nos rins\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Pedras nos rins\"\n                            >\n                    Pedras nos rins                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1602922\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1602922\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1602922]\"\n                                value=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                            >\n                    Infec\u00e7\u00e3o urin\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1535455\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina alcalina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1535455\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1535455]\"\n                                value=\"Urina alcalina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina alcalina\"\n                            >\n                    Urina alcalina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1245702\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina acinzentada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1245702\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1245702]\"\n                                value=\"Urina acinzentada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina acinzentada\"\n                            >\n                    Urina acinzentada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1767736\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina alaranjada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1767736\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1767736]\"\n                                value=\"Urina alaranjada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina alaranjada\"\n                            >\n                    Urina alaranjada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1617480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina escura ou turva\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1617480\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1617480]\"\n                                value=\"Urina escura ou turva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina escura ou turva\"\n                            >\n                    Urina escura ou turva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1153349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina com pus (nublada)\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1153349\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1153349]\"\n                                value=\"Urina com pus (nublada)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina com pus (nublada)\"\n                            >\n                    Urina com pus (nublada)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1981778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina com sangue\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1981778\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1981778]\"\n                                value=\"Urina com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina com sangue\"\n                            >\n                    Urina com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt1150186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina com odor adocicado\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt1150186\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt1150186]\"\n                                value=\"Urina com odor adocicado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina com odor adocicado\"\n                            >\n                    Urina com odor adocicado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt2023561\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Urina com odor forte\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt2023561\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt2023561]\"\n                                value=\"Urina com odor forte\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Urina com odor forte\"\n                            >\n                    Urina com odor forte                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_1_opt2009239\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_1\" data-parsley-multiple=\"fld_1996962_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_1_opt2009239\"\n                                class=\"fld_1996962_1 option-required\"\n                                name=\"fld_1996962[opt2009239]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6823998_1\" data-field-id=\"fld_6823998_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_4596590\" class=\"form-group\" id=\"fld_4596590_1-wrap\">\r\n\t<label id=\"fld_4596590Label\" for=\"fld_4596590_1\" class=\"control-label\">Artrite <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1699194\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1699194\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1699194]\"\n                                value=\"Dor - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Ombros\"\n                            >\n                    Dor - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1269183\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1269183\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1269183]\"\n                                value=\"Dor - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Pulsos\"\n                            >\n                    Dor - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt2000347\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt2000347\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt2000347]\"\n                                value=\"Dor - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - M\u00e3os\"\n                            >\n                    Dor - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1595429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1595429\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1595429]\"\n                                value=\"Dor - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Dedos das m\u00e3os\"\n                            >\n                    Dor - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1657992\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1657992\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1657992]\"\n                                value=\"Dor - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Joelhos\"\n                            >\n                    Dor - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1692539\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1692539\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1692539]\"\n                                value=\"Dor - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Pernas\"\n                            >\n                    Dor - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1992237\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1992237\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1992237]\"\n                                value=\"Dor - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Tornozelos\"\n                            >\n                    Dor - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt2068651\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt2068651\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt2068651]\"\n                                value=\"Dor - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - P\u00e9s\"\n                            >\n                    Dor - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1566573\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Dor - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1566573\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1566573]\"\n                                value=\"Dor - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Dor - Dedos dos p\u00e9s\"\n                            >\n                    Dor - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1274377\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1274377\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1274377]\"\n                                value=\"Incha\u00e7o - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Ombros\"\n                            >\n                    Incha\u00e7o - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt2052296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt2052296\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt2052296]\"\n                                value=\"Incha\u00e7o - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Pulsos\"\n                            >\n                    Incha\u00e7o - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1226478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1226478\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1226478]\"\n                                value=\"Incha\u00e7o - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - M\u00e3os\"\n                            >\n                    Incha\u00e7o - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1129380\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1129380\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1129380]\"\n                                value=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                            >\n                    Incha\u00e7o - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1231438\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1231438\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1231438]\"\n                                value=\"Incha\u00e7o - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Joelhos\"\n                            >\n                    Incha\u00e7o - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1180671\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1180671\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1180671]\"\n                                value=\"Incha\u00e7o - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Pernas\"\n                            >\n                    Incha\u00e7o - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1577258\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1577258\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1577258]\"\n                                value=\"Incha\u00e7o - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Tornozelos\"\n                            >\n                    Incha\u00e7o - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1620672\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1620672\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1620672]\"\n                                value=\"Incha\u00e7o - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - P\u00e9s\"\n                            >\n                    Incha\u00e7o - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1984597\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1984597\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1984597]\"\n                                value=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                            >\n                    Incha\u00e7o - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1868483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1868483\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1868483]\"\n                                value=\"Enrijecimento - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Ombros\"\n                            >\n                    Enrijecimento - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1676038\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1676038\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1676038]\"\n                                value=\"Enrijecimento - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Pulsos\"\n                            >\n                    Enrijecimento - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1255321\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1255321\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1255321]\"\n                                value=\"Enrijecimento - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - M\u00e3os\"\n                            >\n                    Enrijecimento - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1413930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1413930\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1413930]\"\n                                value=\"Enrijecimento - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Dedos das m\u00e3os\"\n                            >\n                    Enrijecimento - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1663405\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1663405\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1663405]\"\n                                value=\"Enrijecimento - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Joelhos\"\n                            >\n                    Enrijecimento - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1675771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1675771\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1675771]\"\n                                value=\"Enrijecimento - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Pernas\"\n                            >\n                    Enrijecimento - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1897509\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1897509\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1897509]\"\n                                value=\"Enrijecimento - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Tornozelos\"\n                            >\n                    Enrijecimento - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1261729\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1261729\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1261729]\"\n                                value=\"Enrijecimento - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - P\u00e9s\"\n                            >\n                    Enrijecimento - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1728510\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1728510\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1728510]\"\n                                value=\"Enrijecimento - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Enrijecimento - Dedos dos p\u00e9s\"\n                            >\n                    Enrijecimento - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1120034\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1120034\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1120034]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_1_opt1542226\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_1\" data-parsley-multiple=\"fld_4596590_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_1_opt1542226\"\n                                class=\"fld_4596590_1 option-required\"\n                                name=\"fld_4596590[opt1542226]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2377312_1\" data-field-id=\"fld_2377312_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-46\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7925824\" class=\"form-group\" id=\"fld_7925824_1-wrap\">\r\n\t<label id=\"fld_7925824Label\" for=\"fld_7925824_1\" class=\"control-label\">Articula\u00e7\u00f5es, \u00d3sseas e Muscular <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt2070517\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor lombar (superior ou inferior)\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt2070517\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt2070517]\"\n                                value=\"Dor lombar (superior ou inferior)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor lombar (superior ou inferior)\"\n                            >\n                    Dor lombar (superior ou inferior)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1879733\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Ossos quebrados (atualmente ou recuperados)\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1879733\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1879733]\"\n                                value=\"Ossos quebrados (atualmente ou recuperados)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Ossos quebrados (atualmente ou recuperados)\"\n                            >\n                    Ossos quebrados (atualmente ou recuperados)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1156486\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Osteoartrite\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1156486\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1156486]\"\n                                value=\"Osteoartrite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Osteoartrite\"\n                            >\n                    Osteoartrite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1529985\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Artrite reumatoide\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1529985\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1529985]\"\n                                value=\"Artrite reumatoide\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Artrite reumatoide\"\n                            >\n                    Artrite reumatoide                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1328416\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Rigidez nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1328416\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1328416]\"\n                                value=\"Rigidez nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Rigidez nas articula\u00e7\u00f5es\"\n                            >\n                    Rigidez nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1118223\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1118223\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1118223]\"\n                                value=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                            >\n                    Incha\u00e7o nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1125281\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1125281\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1125281]\"\n                                value=\"Dor nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor nas articula\u00e7\u00f5es\"\n                            >\n                    Dor nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt2085805\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor muscular\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt2085805\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt2085805]\"\n                                value=\"Dor muscular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor muscular\"\n                            >\n                    Dor muscular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1580703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor no pesco\u00e7o\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1580703\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1580703]\"\n                                value=\"Dor no pesco\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor no pesco\u00e7o\"\n                            >\n                    Dor no pesco\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1557488\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor nas costas\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1557488\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1557488]\"\n                                value=\"Dor nas costas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor nas costas\"\n                            >\n                    Dor nas costas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1693479\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Dor na face\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1693479\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1693479]\"\n                                value=\"Dor na face\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Dor na face\"\n                            >\n                    Dor na face                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1327275\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1327275\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1327275]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_1_opt1864395\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_1\" data-parsley-multiple=\"fld_7925824_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_1_opt1864395\"\n                                class=\"fld_7925824_1 option-required\"\n                                name=\"fld_7925824[opt1864395]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_4147300_1\" data-field-id=\"fld_4147300_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9756699\" class=\"form-group\" id=\"fld_9756699_1-wrap\">\r\n\t<label id=\"fld_9756699Label\" for=\"fld_9756699_1\" class=\"control-label\">Ouvidos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1470447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Cera excessiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1470447\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1470447]\"\n                                value=\"Cera excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Cera excessiva\"\n                            >\n                    Cera excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1791762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Coceira no canal auditivo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1791762\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1791762]\"\n                                value=\"Coceira no canal auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Coceira no canal auditivo\"\n                            >\n                    Coceira no canal auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1991209\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema no canal auditivo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1991209\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1991209]\"\n                                value=\"Eczema no canal auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Eczema no canal auditivo\"\n                            >\n                    Eczema no canal auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1754078\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Dor atr\u00e1s\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1754078\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1754078]\"\n                                value=\"Dor atr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Dor atr\u00e1s\"\n                            >\n                    Dor atr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1695221\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Dor do lado direito\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1695221\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1695221]\"\n                                value=\"Dor do lado direito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Dor do lado direito\"\n                            >\n                    Dor do lado direito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1435185\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Dor do lado esquerdo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1435185\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1435185]\"\n                                value=\"Dor do lado esquerdo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Dor do lado esquerdo\"\n                            >\n                    Dor do lado esquerdo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1114533\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Flu\u00eddos\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1114533\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1114533]\"\n                                value=\"Flu\u00eddos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Flu\u00eddos\"\n                            >\n                    Flu\u00eddos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1464530\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Inflama\u00e7\u00e3o\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1464530\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1464530]\"\n                                value=\"Inflama\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Inflama\u00e7\u00e3o\"\n                            >\n                    Inflama\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1180522\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o recorrente\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1180522\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1180522]\"\n                                value=\"Infec\u00e7\u00e3o recorrente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o recorrente\"\n                            >\n                    Infec\u00e7\u00e3o recorrente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1247581\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Zumbido\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1247581\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1247581]\"\n                                value=\"Zumbido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Zumbido\"\n                            >\n                    Zumbido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1216123\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Ru\u00eddos\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1216123\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1216123]\"\n                                value=\"Ru\u00eddos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Ru\u00eddos\"\n                            >\n                    Ru\u00eddos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1645416\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Defici\u00eancia auditiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1645416\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1645416]\"\n                                value=\"Defici\u00eancia auditiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Defici\u00eancia auditiva\"\n                            >\n                    Defici\u00eancia auditiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1277862\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Perda auditiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1277862\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1277862]\"\n                                value=\"Perda auditiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Perda auditiva\"\n                            >\n                    Perda auditiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1633597\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1633597\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1633597]\"\n                                value=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                            >\n                    Orelhas - Ulcera\u00e7\u00e3o na frente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1212164\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1212164\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1212164]\"\n                                value=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                            >\n                    Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1487107\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Outros problemas\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1487107\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1487107]\"\n                                value=\"Orelhas - Outros problemas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Orelhas - Outros problemas\"\n                            >\n                    Orelhas - Outros problemas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1053055\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1053055\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1053055]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_1_opt1319779\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_1\" data-parsley-multiple=\"fld_9756699_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_1_opt1319779\"\n                                class=\"fld_9756699_1 option-required\"\n                                name=\"fld_9756699[opt1319779]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6128378_1\" data-field-id=\"fld_6128378_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-47\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5201432\" class=\"form-group\" id=\"fld_5201432_1-wrap\">\r\n\t<label id=\"fld_5201432Label\" for=\"fld_5201432_1\" class=\"control-label\">Olhos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1702665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edveis\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1702665\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1702665]\"\n                                value=\"Sens\u00edveis\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Sens\u00edveis\"\n                            >\n                    Sens\u00edveis                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1300715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Coceira\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1300715\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1300715]\"\n                                value=\"Coceira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Coceira\"\n                            >\n                    Coceira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1243192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Descargas\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1243192\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1243192]\"\n                                value=\"Descargas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Descargas\"\n                            >\n                    Descargas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1424542\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Queima\u00e7\u00e3o\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1424542\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1424542]\"\n                                value=\"Queima\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Queima\u00e7\u00e3o\"\n                            >\n                    Queima\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1840502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Dor\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1840502\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1840502]\"\n                                value=\"Dor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Dor\"\n                            >\n                    Dor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1450274\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Secos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1450274\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1450274]\"\n                                value=\"Secos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Secos\"\n                            >\n                    Secos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1548588\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Marejados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1548588\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1548588]\"\n                                value=\"Marejados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Marejados\"\n                            >\n                    Marejados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt2061189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Aguados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt2061189\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt2061189]\"\n                                value=\"Aguados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Aguados\"\n                            >\n                    Aguados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1531376\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Afundados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1531376\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1531376]\"\n                                value=\"Afundados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Afundados\"\n                            >\n                    Afundados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1091312\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Vermelhos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1091312\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1091312]\"\n                                value=\"Vermelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Vermelhos\"\n                            >\n                    Vermelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1631585\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Sujeira\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1631585\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1631585]\"\n                                value=\"Sujeira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Sujeira\"\n                            >\n                    Sujeira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt2061891\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Miopia \"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt2061891\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt2061891]\"\n                                value=\"Miopia \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Miopia \"\n                            >\n                    Miopia                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1395599\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Diplopia \"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1395599\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1395599]\"\n                                value=\"Diplopia \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Diplopia \"\n                            >\n                    Diplopia                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1719212\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Estrabismo\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1719212\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1719212]\"\n                                value=\"Estrabismo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Estrabismo\"\n                            >\n                    Estrabismo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1349457\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Fotofobia\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1349457\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1349457]\"\n                                value=\"Fotofobia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Fotofobia\"\n                            >\n                    Fotofobia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1736109\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o fraca\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1736109\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1736109]\"\n                                value=\"Vis\u00e3o fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Vis\u00e3o fraca\"\n                            >\n                    Vis\u00e3o fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1216680\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o turva\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1216680\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1216680]\"\n                                value=\"Vis\u00e3o turva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Vis\u00e3o turva\"\n                            >\n                    Vis\u00e3o turva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1590813\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o tunelada\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1590813\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1590813]\"\n                                value=\"Vis\u00e3o tunelada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Vis\u00e3o tunelada\"\n                            >\n                    Vis\u00e3o tunelada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1834218\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o falhando ou em agravamento\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1834218\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1834218]\"\n                                value=\"Vis\u00e3o falhando ou em agravamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Vis\u00e3o falhando ou em agravamento\"\n                            >\n                    Vis\u00e3o falhando ou em agravamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt2057082\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Sangramento\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt2057082\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt2057082]\"\n                                value=\"Sangramento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Sangramento\"\n                            >\n                    Sangramento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1935262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"P\u00e1lpebras inchadas\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1935262\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1935262]\"\n                                value=\"P\u00e1lpebras inchadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"P\u00e1lpebras inchadas\"\n                            >\n                    P\u00e1lpebras inchadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1899376\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Escuro sob os olhos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1899376\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1899376]\"\n                                value=\"Escuro sob os olhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Escuro sob os olhos\"\n                            >\n                    Escuro sob os olhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1603109\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1603109\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1603109]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_1_opt1344095\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_1\" data-parsley-multiple=\"fld_5201432_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_1_opt1344095\"\n                                class=\"fld_5201432_1 option-required\"\n                                name=\"fld_5201432[opt1344095]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7039225_1\" data-field-id=\"fld_7039225_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1904780\" class=\"form-group\" id=\"fld_1904780_1-wrap\">\r\n\t<label id=\"fld_1904780Label\" for=\"fld_1904780_1\" class=\"control-label\">Nariz <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1059988\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Longo\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1059988\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1059988]\"\n                                value=\"Longo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Longo\"\n                            >\n                    Longo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1771630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Torto\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1771630\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1771630]\"\n                                value=\"Torto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Torto\"\n                            >\n                    Torto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1631600\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Ponta fria\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1631600\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1631600]\"\n                                value=\"Ponta fria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Ponta fria\"\n                            >\n                    Ponta fria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1858031\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Ponta vermelha\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1858031\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1858031]\"\n                                value=\"Ponta vermelha\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Ponta vermelha\"\n                            >\n                    Ponta vermelha                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1202958\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edvel a odores\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1202958\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1202958]\"\n                                value=\"Sens\u00edvel a odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Sens\u00edvel a odores\"\n                            >\n                    Sens\u00edvel a odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt2013506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Narina seca\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt2013506\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt2013506]\"\n                                value=\"Narina seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Narina seca\"\n                            >\n                    Narina seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1991210\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Secre\u00e7\u00e3o seca\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1991210\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1991210]\"\n                                value=\"Secre\u00e7\u00e3o seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Secre\u00e7\u00e3o seca\"\n                            >\n                    Secre\u00e7\u00e3o seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1062391\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade em respirar\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1062391\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1062391]\"\n                                value=\"Dificuldade em respirar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Dificuldade em respirar\"\n                            >\n                    Dificuldade em respirar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt2076560\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Congestionado\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt2076560\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt2076560]\"\n                                value=\"Congestionado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Congestionado\"\n                            >\n                    Congestionado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1241777\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1241777\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1241777]\"\n                                value=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                            >\n                    Infec\u00e7\u00e3o do s\u00ednus (sinusite)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1534493\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1534493\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1534493]\"\n                                value=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                            >\n                    Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1195709\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1195709\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1195709]\"\n                                value=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                            >\n                    Descarga de secre\u00e7\u00e3o na narina direita                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1737232\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1737232\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1737232]\"\n                                value=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                            >\n                    Descarga de secre\u00e7\u00e3o na narina esquerda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1341485\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Gotejamento p\u00f3s-nasal\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1341485\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1341485]\"\n                                value=\"Gotejamento p\u00f3s-nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Gotejamento p\u00f3s-nasal\"\n                            >\n                    Gotejamento p\u00f3s-nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1416185\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"\u00dalceras\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1416185\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1416185]\"\n                                value=\"\u00dalceras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"\u00dalceras\"\n                            >\n                    \u00dalceras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1496051\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Congestionado com sangue\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1496051\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1496051]\"\n                                value=\"Congestionado com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Congestionado com sangue\"\n                            >\n                    Congestionado com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1977715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Sangramento nasal\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1977715\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1977715]\"\n                                value=\"Sangramento nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Sangramento nasal\"\n                            >\n                    Sangramento nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1335797\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1335797\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1335797]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_1_opt1546581\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_1\" data-parsley-multiple=\"fld_1904780_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_1_opt1546581\"\n                                class=\"fld_1904780_1 option-required\"\n                                name=\"fld_1904780[opt1546581]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_224762_1\" data-field-id=\"fld_224762_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-48\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_1289525\" class=\"form-group\" id=\"fld_1289525_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_1289525\" id=\"fld_1289525_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_1289525\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_1289525\" id=\"fld_1289525_1_btn\" value=\"\" data-field=\"fld_1289525\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3354932\" class=\"form-group\" id=\"fld_3354932_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_3354932\" id=\"fld_3354932_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_3354932\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_3354932\" id=\"fld_3354932_1_btn\" value=\"\" data-field=\"fld_3354932\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3152327\" class=\"form-group\" id=\"fld_3152327_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_3152327\" id=\"fld_3152327_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_3152327\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_3152327\" id=\"fld_3152327_1_btn\" value=\"\" data-field=\"fld_3152327\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_9\" data-formpage=\"9\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_9\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-49\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1633260\" class=\"form-group\" id=\"fld_1633260_1-wrap\">\r\n\t<label id=\"fld_1633260Label\" for=\"fld_1633260_1\" class=\"control-label\">L\u00e1bios, Boca e Dentes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1212738\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios inchados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1212738\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1212738]\"\n                                value=\"L\u00e1bios inchados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00e1bios inchados\"\n                            >\n                    L\u00e1bios inchados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt2058227\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios rachados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt2058227\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt2058227]\"\n                                value=\"L\u00e1bios rachados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00e1bios rachados\"\n                            >\n                    L\u00e1bios rachados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt2088266\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios secos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt2088266\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt2088266]\"\n                                value=\"L\u00e1bios secos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00e1bios secos\"\n                            >\n                    L\u00e1bios secos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1451843\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Herpes labial\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1451843\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1451843]\"\n                                value=\"Herpes labial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Herpes labial\"\n                            >\n                    Herpes labial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1704766\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Mau h\u00e1lito\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1704766\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1704766]\"\n                                value=\"Mau h\u00e1lito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Mau h\u00e1lito\"\n                            >\n                    Mau h\u00e1lito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt2069487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Gosto amargo\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt2069487\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt2069487]\"\n                                value=\"Gosto amargo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Gosto amargo\"\n                            >\n                    Gosto amargo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1301843\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Afta\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1301843\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1301843]\"\n                                value=\"Afta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Afta\"\n                            >\n                    Afta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt2089863\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"\u00dalcera\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt2089863\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt2089863]\"\n                                value=\"\u00dalcera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"\u00dalcera\"\n                            >\n                    \u00dalcera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1946794\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua para fora\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1946794\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1946794]\"\n                                value=\"L\u00edngua para fora\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00edngua para fora\"\n                            >\n                    L\u00edngua para fora                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1385555\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua descolorada\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1385555\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1385555]\"\n                                value=\"L\u00edngua descolorada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00edngua descolorada\"\n                            >\n                    L\u00edngua descolorada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1418437\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua com feridas\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1418437\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1418437]\"\n                                value=\"L\u00edngua com feridas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"L\u00edngua com feridas\"\n                            >\n                    L\u00edngua com feridas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1375826\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Boca seca\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1375826\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1375826]\"\n                                value=\"Boca seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Boca seca\"\n                            >\n                    Boca seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1843526\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Saliva\u00e7\u00e3o excessiva\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1843526\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1843526]\"\n                                value=\"Saliva\u00e7\u00e3o excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Saliva\u00e7\u00e3o excessiva\"\n                            >\n                    Saliva\u00e7\u00e3o excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1337285\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Babando\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1337285\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1337285]\"\n                                value=\"Babando\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Babando\"\n                            >\n                    Babando                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1709296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade na fala\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1709296\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1709296]\"\n                                value=\"Dificuldade na fala\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dificuldade na fala\"\n                            >\n                    Dificuldade na fala                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt2054780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes retangulares\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt2054780\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt2054780]\"\n                                value=\"Dentes retangulares\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes retangulares\"\n                            >\n                    Dentes retangulares                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1406420\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes curtos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1406420\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1406420]\"\n                                value=\"Dentes curtos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes curtos\"\n                            >\n                    Dentes curtos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1235535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes longos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1235535\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1235535]\"\n                                value=\"Dentes longos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes longos\"\n                            >\n                    Dentes longos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1960296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes assim\u00e9tricos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1960296\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1960296]\"\n                                value=\"Dentes assim\u00e9tricos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes assim\u00e9tricos\"\n                            >\n                    Dentes assim\u00e9tricos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1602653\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes amarelados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1602653\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1602653]\"\n                                value=\"Dentes amarelados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes amarelados\"\n                            >\n                    Dentes amarelados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1126303\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes verdes\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1126303\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1126303]\"\n                                value=\"Dentes verdes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes verdes\"\n                            >\n                    Dentes verdes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1424003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes pretos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1424003\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1424003]\"\n                                value=\"Dentes pretos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes pretos\"\n                            >\n                    Dentes pretos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1666021\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes soltos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1666021\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1666021]\"\n                                value=\"Dentes soltos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes soltos\"\n                            >\n                    Dentes soltos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1749860\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes perdidos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1749860\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1749860]\"\n                                value=\"Dentes perdidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes perdidos\"\n                            >\n                    Dentes perdidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1891015\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1891015\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1891015]\"\n                                value=\"Dentes sens\u00edveis\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes sens\u00edveis\"\n                            >\n                    Dentes sens\u00edveis                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1992471\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis ao frio\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1992471\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1992471]\"\n                                value=\"Dentes sens\u00edveis ao frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes sens\u00edveis ao frio\"\n                            >\n                    Dentes sens\u00edveis ao frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1064182\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1064182\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1064182]\"\n                                value=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                            >\n                    Dentes sens\u00edveis a mastiga\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1174082\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Dentes com numerosas c\u00e1ries\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1174082\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1174082]\"\n                                value=\"Dentes com numerosas c\u00e1ries\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Dentes com numerosas c\u00e1ries\"\n                            >\n                    Dentes com numerosas c\u00e1ries                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1125627\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Ranger dos dentes (bruxismo)\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1125627\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1125627]\"\n                                value=\"Ranger dos dentes (bruxismo)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Ranger dos dentes (bruxismo)\"\n                            >\n                    Ranger dos dentes (bruxismo)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1793466\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Abscesso na gengiva\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1793466\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1793466]\"\n                                value=\"Abscesso na gengiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Abscesso na gengiva\"\n                            >\n                    Abscesso na gengiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1828344\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Sangramento gengival\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1828344\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1828344]\"\n                                value=\"Sangramento gengival\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Sangramento gengival\"\n                            >\n                    Sangramento gengival                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1731016\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1731016\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1731016]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_1_opt1642604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_1\" data-parsley-multiple=\"fld_1633260_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_1_opt1642604\"\n                                class=\"fld_1633260_1 option-required\"\n                                name=\"fld_1633260[opt1642604]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_973027_1\" data-field-id=\"fld_973027_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9478261\" class=\"form-group\" id=\"fld_9478261_1-wrap\">\r\n\t<label id=\"fld_9478261Label\" for=\"fld_9478261_1\" class=\"control-label\">Garganta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt2061916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Dor de garganta\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt2061916\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt2061916]\"\n                                value=\"Dor de garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Dor de garganta\"\n                            >\n                    Dor de garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1721721\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Garganta inflamada\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1721721\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1721721]\"\n                                value=\"Garganta inflamada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Garganta inflamada\"\n                            >\n                    Garganta inflamada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1956052\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Garganta infeccionada\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1956052\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1956052]\"\n                                value=\"Garganta infeccionada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Garganta infeccionada\"\n                            >\n                    Garganta infeccionada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1771132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Garganta seca\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1771132\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1771132]\"\n                                value=\"Garganta seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Garganta seca\"\n                            >\n                    Garganta seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1239192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Muco excessivo\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1239192\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1239192]\"\n                                value=\"Muco excessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Muco excessivo\"\n                            >\n                    Muco excessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1805943\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Ferida\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1805943\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1805943]\"\n                                value=\"Ferida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Ferida\"\n                            >\n                    Ferida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1930858\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de degluti\u00e7\u00e3o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1930858\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1930858]\"\n                                value=\"Dificuldade de degluti\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Dificuldade de degluti\u00e7\u00e3o\"\n                            >\n                    Dificuldade de degluti\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1203693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Dor ao deglutir\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1203693\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1203693]\"\n                                value=\"Dor ao deglutir\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Dor ao deglutir\"\n                            >\n                    Dor ao deglutir                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1828090\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Rouquid\u00e3o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1828090\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1828090]\"\n                                value=\"Rouquid\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Rouquid\u00e3o\"\n                            >\n                    Rouquid\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1141114\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Perda de voz\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1141114\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1141114]\"\n                                value=\"Perda de voz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Perda de voz\"\n                            >\n                    Perda de voz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1131794\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de asfixia\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1131794\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1131794]\"\n                                value=\"Sensa\u00e7\u00e3o de asfixia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de asfixia\"\n                            >\n                    Sensa\u00e7\u00e3o de asfixia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt2029156\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt2029156\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt2029156]\"\n                                value=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                            >\n                    Sensa\u00e7\u00e3o de caro\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1711950\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de estreitamento\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1711950\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1711950]\"\n                                value=\"Sensa\u00e7\u00e3o de estreitamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de estreitamento\"\n                            >\n                    Sensa\u00e7\u00e3o de estreitamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt2005930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Amigdalite\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt2005930\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt2005930]\"\n                                value=\"Amigdalite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Amigdalite\"\n                            >\n                    Amigdalite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1086026\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Aden\u00f3ides\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1086026\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1086026]\"\n                                value=\"Aden\u00f3ides\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Aden\u00f3ides\"\n                            >\n                    Aden\u00f3ides                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1647454\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1647454\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1647454]\"\n                                value=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                            >\n                    Externo - Endurecimento das gl\u00e2ndulas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt2068101\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt2068101\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt2068101]\"\n                                value=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                            >\n                    Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1338042\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Externo - B\u00f3cio\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1338042\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1338042]\"\n                                value=\"Externo - B\u00f3cio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Externo - B\u00f3cio\"\n                            >\n                    Externo - B\u00f3cio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1406752\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1406752\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1406752]\"\n                                value=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                            >\n                    Externo - Dor na gl\u00e2ndula tire\u00f3ide                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1450963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1450963\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1450963]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_1_opt1558277\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_1\" data-parsley-multiple=\"fld_9478261_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_1_opt1558277\"\n                                class=\"fld_9478261_1 option-required\"\n                                name=\"fld_9478261[opt1558277]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7301016_1\" data-field-id=\"fld_7301016_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-50\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_78322\" class=\"form-group\" id=\"fld_78322_1-wrap\">\r\n\t<label id=\"fld_78322Label\" for=\"fld_78322_1\" class=\"control-label\">Pele <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1512013\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Saud\u00e1vel\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1512013\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1512013]\"\n                                value=\"Saud\u00e1vel\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Saud\u00e1vel\"\n                            >\n                    Saud\u00e1vel                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1426853\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Corada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1426853\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1426853]\"\n                                value=\"Corada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Corada\"\n                            >\n                    Corada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1259630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Descolorada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1259630\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1259630]\"\n                                value=\"Descolorada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Descolorada\"\n                            >\n                    Descolorada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt2005373\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Sardas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt2005373\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt2005373]\"\n                                value=\"Sardas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Sardas\"\n                            >\n                    Sardas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1544480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Machada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1544480\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1544480]\"\n                                value=\"Machada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Machada\"\n                            >\n                    Machada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1928177\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Seca\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1928177\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1928177]\"\n                                value=\"Seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Seca\"\n                            >\n                    Seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1359303\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Oleosa\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1359303\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1359303]\"\n                                value=\"Oleosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Oleosa\"\n                            >\n                    Oleosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1384394\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Sudorese excessiva\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1384394\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1384394]\"\n                                value=\"Sudorese excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Sudorese excessiva\"\n                            >\n                    Sudorese excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1962010\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Fina\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1962010\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1962010]\"\n                                value=\"Fina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Fina\"\n                            >\n                    Fina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1871125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Porcelana\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1871125\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1871125]\"\n                                value=\"Porcelana\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Porcelana\"\n                            >\n                    Porcelana                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1702484\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Coceira\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1702484\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1702484]\"\n                                value=\"Coceira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Coceira\"\n                            >\n                    Coceira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1195639\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Acne (espinhas e cravos)\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1195639\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1195639]\"\n                                value=\"Acne (espinhas e cravos)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Acne (espinhas e cravos)\"\n                            >\n                    Acne (espinhas e cravos)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1869944\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Verrugas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1869944\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1869944]\"\n                                value=\"Verrugas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Verrugas\"\n                            >\n                    Verrugas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1528943\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Prurido\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1528943\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1528943]\"\n                                value=\"Prurido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Prurido\"\n                            >\n                    Prurido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1153594\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Urtic\u00e1rias\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1153594\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1153594]\"\n                                value=\"Urtic\u00e1rias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Urtic\u00e1rias\"\n                            >\n                    Urtic\u00e1rias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1824266\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Fur\u00fanculos\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1824266\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1824266]\"\n                                value=\"Fur\u00fanculos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Fur\u00fanculos\"\n                            >\n                    Fur\u00fanculos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1878526\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Psoriase\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1878526\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1878526]\"\n                                value=\"Psoriase\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Psoriase\"\n                            >\n                    Psoriase                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1815649\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Cistos\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1815649\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1815649]\"\n                                value=\"Cistos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Cistos\"\n                            >\n                    Cistos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1691667\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00f5es\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1691667\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1691667]\"\n                                value=\"Infec\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Infec\u00e7\u00f5es\"\n                            >\n                    Infec\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1050669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1050669\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1050669]\"\n                                value=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                            >\n                    Erup\u00e7\u00f5es cut\u00e2neas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1315707\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Veias varicosas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1315707\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1315707]\"\n                                value=\"Veias varicosas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Veias varicosas\"\n                            >\n                    Veias varicosas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1925880\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Veias quebradas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1925880\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1925880]\"\n                                value=\"Veias quebradas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Veias quebradas\"\n                            >\n                    Veias quebradas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1907849\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1907849\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1907849]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_1_opt1220515\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_1\" data-parsley-multiple=\"fld_78322_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_1_opt1220515\"\n                                class=\"fld_78322_1 option-required\"\n                                name=\"fld_78322[opt1220515]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1855499_1\" data-field-id=\"fld_1855499_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6108732\" class=\"form-group\" id=\"fld_6108732_1-wrap\">\r\n\t<label id=\"fld_6108732Label\" for=\"fld_6108732_1\" class=\"control-label\">Eczema, Psor\u00edase e Comich\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1238487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Rosto\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1238487\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1238487]\"\n                                value=\"Eczema - Rosto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Rosto\"\n                            >\n                    Eczema - Rosto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1396127\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Pesco\u00e7o\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1396127\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1396127]\"\n                                value=\"Eczema - Pesco\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Pesco\u00e7o\"\n                            >\n                    Eczema - Pesco\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1050856\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Bra\u00e7o\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1050856\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1050856]\"\n                                value=\"Eczema - Bra\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Bra\u00e7o\"\n                            >\n                    Eczema - Bra\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1164181\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - M\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1164181\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1164181]\"\n                                value=\"Eczema - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - M\u00e3os\"\n                            >\n                    Eczema - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1470740\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Dedos das m\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1470740\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1470740]\"\n                                value=\"Eczema - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Dedos das m\u00e3os\"\n                            >\n                    Eczema - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1241502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Perna\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1241502\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1241502]\"\n                                value=\"Eczema - Perna\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Perna\"\n                            >\n                    Eczema - Perna                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1154167\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1154167\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1154167]\"\n                                value=\"Eczema - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - P\u00e9s\"\n                            >\n                    Eczema - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1363616\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Dedo dos P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1363616\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1363616]\"\n                                value=\"Eczema - Dedo dos P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Dedo dos P\u00e9s\"\n                            >\n                    Eczema - Dedo dos P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1365821\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Genitais\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1365821\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1365821]\"\n                                value=\"Eczema - Genitais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - Genitais\"\n                            >\n                    Eczema - Genitais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1939514\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Eczema - \u00c2nus\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1939514\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1939514]\"\n                                value=\"Eczema - \u00c2nus\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Eczema - \u00c2nus\"\n                            >\n                    Eczema - \u00c2nus                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt2040612\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase -  Cotovelo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt2040612\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt2040612]\"\n                                value=\"Psor\u00edase -  Cotovelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Psor\u00edase -  Cotovelo\"\n                            >\n                    Psor\u00edase -  Cotovelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1210397\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Dobra do cotovelo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1210397\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1210397]\"\n                                value=\"Psor\u00edase - Dobra do cotovelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Psor\u00edase - Dobra do cotovelo\"\n                            >\n                    Psor\u00edase - Dobra do cotovelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1871285\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Joelho\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1871285\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1871285]\"\n                                value=\"Psor\u00edase - Joelho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Psor\u00edase - Joelho\"\n                            >\n                    Psor\u00edase - Joelho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1124039\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Dobra do joelho\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1124039\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1124039]\"\n                                value=\"Psor\u00edase - Dobra do joelho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Psor\u00edase - Dobra do joelho\"\n                            >\n                    Psor\u00edase - Dobra do joelho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1078232\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Couro cabeludo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1078232\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1078232]\"\n                                value=\"Comich\u00e3o - Couro cabeludo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - Couro cabeludo\"\n                            >\n                    Comich\u00e3o - Couro cabeludo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1569762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Rosto\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1569762\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1569762]\"\n                                value=\"Comich\u00e3o - Rosto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - Rosto\"\n                            >\n                    Comich\u00e3o - Rosto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1760304\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Cotovelos\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1760304\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1760304]\"\n                                value=\"Comich\u00e3o - Cotovelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - Cotovelos\"\n                            >\n                    Comich\u00e3o - Cotovelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1710701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - M\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1710701\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1710701]\"\n                                value=\"Comich\u00e3o - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - M\u00e3os\"\n                            >\n                    Comich\u00e3o - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1501755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Joelhos\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1501755\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1501755]\"\n                                value=\"Comich\u00e3o - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - Joelhos\"\n                            >\n                    Comich\u00e3o - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1371984\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1371984\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1371984]\"\n                                value=\"Comich\u00e3o - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Comich\u00e3o - P\u00e9s\"\n                            >\n                    Comich\u00e3o - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1442481\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1442481\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1442481]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_1_opt1440402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_1\" data-parsley-multiple=\"fld_6108732_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_1_opt1440402\"\n                                class=\"fld_6108732_1 option-required\"\n                                name=\"fld_6108732[opt1440402]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9690541_1\" data-field-id=\"fld_9690541_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-51\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6841849\" class=\"form-group\" id=\"fld_6841849_1-wrap\">\r\n\t<label id=\"fld_6841849Label\" for=\"fld_6841849_1\" class=\"control-label\">Couro Cabeludo <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1227697\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Seco\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1227697\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1227697]\"\n                                value=\"Seco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Seco\"\n                            >\n                    Seco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1414270\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Oleoso\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1414270\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1414270]\"\n                                value=\"Oleoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Oleoso\"\n                            >\n                    Oleoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1325605\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Caspa\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1325605\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1325605]\"\n                                value=\"Caspa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Caspa\"\n                            >\n                    Caspa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1099916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Queda de cabelo\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1099916\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1099916]\"\n                                value=\"Queda de cabelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Queda de cabelo\"\n                            >\n                    Queda de cabelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1240555\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Cavo\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1240555\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1240555]\"\n                                value=\"Cavo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Cavo\"\n                            >\n                    Cavo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_1_opt1982355\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_1\" data-parsley-multiple=\"fld_6841849_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_1_opt1982355\"\n                                class=\"fld_6841849_1 option-required\"\n                                name=\"fld_6841849[opt1982355]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5947451_1\" data-field-id=\"fld_5947451_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_4421454_1\" data-field-id=\"fld_4421454_1\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7735289_1\" data-field-id=\"fld_7735289_1\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1241280_1\" data-field-id=\"fld_1241280_1\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_437986_1\" data-field-id=\"fld_437986_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-52\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_688914\" class=\"form-group\" id=\"fld_688914_1-wrap\">\r\n\t<label id=\"fld_688914Label\" for=\"fld_688914_1\" class=\"control-label\">Outros <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1362941\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Problema de mem\u00f3ria\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1362941\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1362941]\"\n                                value=\"Problema de mem\u00f3ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Problema de mem\u00f3ria\"\n                            >\n                    Problema de mem\u00f3ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1737042\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Vertigens\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1737042\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1737042]\"\n                                value=\"Vertigens\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Vertigens\"\n                            >\n                    Vertigens                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1191725\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Tontura\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1191725\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1191725]\"\n                                value=\"Tontura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Tontura\"\n                            >\n                    Tontura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1805476\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Desmaio\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1805476\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1805476]\"\n                                value=\"Desmaio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Desmaio\"\n                            >\n                    Desmaio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1081099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Dores de cabe\u00e7a\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1081099\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1081099]\"\n                                value=\"Dores de cabe\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Dores de cabe\u00e7a\"\n                            >\n                    Dores de cabe\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1086357\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Problemas no sono\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1086357\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1086357]\"\n                                value=\"Problemas no sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Problemas no sono\"\n                            >\n                    Problemas no sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1480045\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Ansiedade\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1480045\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1480045]\"\n                                value=\"Ansiedade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Ansiedade\"\n                            >\n                    Ansiedade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1683703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1683703\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1683703]\"\n                                value=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                            >\n                    Altera\u00e7\u00f5es r\u00e1pidas de humor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1752154\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Falta de apetite sexual\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1752154\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1752154]\"\n                                value=\"Falta de apetite sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Falta de apetite sexual\"\n                            >\n                    Falta de apetite sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1463952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Melancolia ou depress\u00e3o\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1463952\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1463952]\"\n                                value=\"Melancolia ou depress\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Melancolia ou depress\u00e3o\"\n                            >\n                    Melancolia ou depress\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt2022132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Pensamento obsessivo\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt2022132\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt2022132]\"\n                                value=\"Pensamento obsessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Pensamento obsessivo\"\n                            >\n                    Pensamento obsessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1621008\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Febres\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1621008\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1621008]\"\n                                value=\"Febres\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Febres\"\n                            >\n                    Febres                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1282989\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Calafrios\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1282989\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1282989]\"\n                                value=\"Calafrios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Calafrios\"\n                            >\n                    Calafrios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt2049076\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Fadiga\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt2049076\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt2049076]\"\n                                value=\"Fadiga\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Fadiga\"\n                            >\n                    Fadiga                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt2064014\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Fraqueza\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt2064014\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt2064014]\"\n                                value=\"Fraqueza\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Fraqueza\"\n                            >\n                    Fraqueza                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1778566\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Tremores\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1778566\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1778566]\"\n                                value=\"Tremores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Tremores\"\n                            >\n                    Tremores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1794012\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Dor nevr\u00e1lgica\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1794012\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1794012]\"\n                                value=\"Dor nevr\u00e1lgica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Dor nevr\u00e1lgica\"\n                            >\n                    Dor nevr\u00e1lgica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1596238\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Perda de peso\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1596238\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1596238]\"\n                                value=\"Perda de peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Perda de peso\"\n                            >\n                    Perda de peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1591715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Ganho de peso\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1591715\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1591715]\"\n                                value=\"Ganho de peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Ganho de peso\"\n                            >\n                    Ganho de peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1816838\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Desconforto em ambientes \u00famidos ou mofados\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1816838\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1816838]\"\n                                value=\"Desconforto em ambientes \u00famidos ou mofados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Desconforto em ambientes \u00famidos ou mofados\"\n                            >\n                    Desconforto em ambientes \u00famidos ou mofados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1546917\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1546917\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1546917]\"\n                                value=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                            >\n                    Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_1_opt1641949\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_1\" data-parsley-multiple=\"fld_688914_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_1_opt1641949\"\n                                class=\"fld_688914_1 option-required\"\n                                name=\"fld_688914[opt1641949]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2791673\" class=\"form-group\" id=\"fld_2791673_1-wrap\">\r\n\t<label id=\"fld_2791673Label\" for=\"fld_2791673_1\" class=\"control-label\">Situa\u00e7\u00e3o n\u00e3o citada anteriormente<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2791673\" value=\"\" data-field=\"fld_2791673\" class=\"form-control\" id=\"fld_2791673_1\" rows=\"4\"    aria-labelledby=\"fld_2791673Label\" aria-describedby=\"fld_2791673Caption\" ><\/textarea>\n\t\t<span id=\"fld_2791673Caption\" class=\"help-block\">Que voc\u00ea ache relevante mencionar<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-53\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_163810\" class=\"form-group\" id=\"fld_163810_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_163810\" id=\"fld_163810_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_163810\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_163810\" id=\"fld_163810_1_btn\" value=\"\" data-field=\"fld_163810\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6865005\" class=\"form-group\" id=\"fld_6865005_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_6865005\" id=\"fld_6865005_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_6865005\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_6865005\" id=\"fld_6865005_1_btn\" value=\"\" data-field=\"fld_6865005\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8261448\" class=\"form-group\" id=\"fld_8261448_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_8261448\" id=\"fld_8261448_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_8261448\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_8261448\" id=\"fld_8261448_1_btn\" value=\"\" data-field=\"fld_8261448\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_10\" data-formpage=\"10\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_10\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-54\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_495397\" class=\"form-group\" id=\"fld_495397_1-wrap\">\r\n\t<label id=\"fld_495397Label\" for=\"fld_495397_1\" class=\"control-label\">Como voc\u00ea v\u00ea seu corpo? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1341765\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Normal\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1341765\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1341765]\"\n                                value=\"Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Normal\"\n                            >\n                    Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1267692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Delgado\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1267692\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1267692]\"\n                                value=\"Delgado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Delgado\"\n                            >\n                    Delgado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1411452\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Gordinho\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1411452\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1411452]\"\n                                value=\"Gordinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Gordinho\"\n                            >\n                    Gordinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1758425\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Abaixo do peso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1758425\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1758425]\"\n                                value=\"Abaixo do peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Abaixo do peso\"\n                            >\n                    Abaixo do peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1445429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Acima do peso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1445429\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1445429]\"\n                                value=\"Acima do peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Acima do peso\"\n                            >\n                    Acima do peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1778788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Estatura alta\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1778788\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1778788]\"\n                                value=\"Estatura alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Estatura alta\"\n                            >\n                    Estatura alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1736760\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Estatura m\u00e9dia\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1736760\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1736760]\"\n                                value=\"Estatura m\u00e9dia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Estatura m\u00e9dia\"\n                            >\n                    Estatura m\u00e9dia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1544298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Estatura baixa\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1544298\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1544298]\"\n                                value=\"Estatura baixa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Estatura baixa\"\n                            >\n                    Estatura baixa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1845746\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Ombros estreitos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1845746\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1845746]\"\n                                value=\"Ombros estreitos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Ombros estreitos\"\n                            >\n                    Ombros estreitos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1633499\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Ombros largos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1633499\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1633499]\"\n                                value=\"Ombros largos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Ombros largos\"\n                            >\n                    Ombros largos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1802465\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Bra\u00e7os finos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1802465\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1802465]\"\n                                value=\"Bra\u00e7os finos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Bra\u00e7os finos\"\n                            >\n                    Bra\u00e7os finos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1818336\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Bra\u00e7os fl\u00e1cidos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1818336\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1818336]\"\n                                value=\"Bra\u00e7os fl\u00e1cidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Bra\u00e7os fl\u00e1cidos\"\n                            >\n                    Bra\u00e7os fl\u00e1cidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1682496\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Abdome liso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1682496\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1682496]\"\n                                value=\"Abdome liso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Abdome liso\"\n                            >\n                    Abdome liso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1106913\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Abdome Fl\u00e1cido\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1106913\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1106913]\"\n                                value=\"Abdome Fl\u00e1cido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Abdome Fl\u00e1cido\"\n                            >\n                    Abdome Fl\u00e1cido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1628440\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Quadril estreito\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1628440\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1628440]\"\n                                value=\"Quadril estreito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Quadril estreito\"\n                            >\n                    Quadril estreito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1772345\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Quadril largo\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1772345\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1772345]\"\n                                value=\"Quadril largo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Quadril largo\"\n                            >\n                    Quadril largo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1936769\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1degas grandes\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1936769\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1936769]\"\n                                value=\"N\u00e1degas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"N\u00e1degas grandes\"\n                            >\n                    N\u00e1degas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1216840\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1degas pequenas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1216840\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1216840]\"\n                                value=\"N\u00e1degas pequenas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"N\u00e1degas pequenas\"\n                            >\n                    N\u00e1degas pequenas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1880535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Coxas torneadas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1880535\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1880535]\"\n                                value=\"Coxas torneadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Coxas torneadas\"\n                            >\n                    Coxas torneadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1901591\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Coxas fl\u00e1cidas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1901591\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1901591]\"\n                                value=\"Coxas fl\u00e1cidas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Coxas fl\u00e1cidas\"\n                            >\n                    Coxas fl\u00e1cidas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1206394\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Pernas finas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1206394\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1206394]\"\n                                value=\"Pernas finas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Pernas finas\"\n                            >\n                    Pernas finas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt2080349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Corpo em forma de ampulheta\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt2080349\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt2080349]\"\n                                value=\"Corpo em forma de ampulheta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Corpo em forma de ampulheta\"\n                            >\n                    Corpo em forma de ampulheta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1198396\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Corpo em forma de pera\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1198396\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1198396]\"\n                                value=\"Corpo em forma de pera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Corpo em forma de pera\"\n                            >\n                    Corpo em forma de pera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_1_opt1586651\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_1\" data-parsley-multiple=\"fld_495397_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_1_opt1586651\"\n                                class=\"fld_495397_1 option-required\"\n                                name=\"fld_495397[opt1586651]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5184946_1\" data-field-id=\"fld_5184946_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6779368\" class=\"form-group\" id=\"fld_6779368_1-wrap\">\r\n\t<label id=\"fld_6779368Label\" for=\"fld_6779368_1\" class=\"control-label\">Como voc\u00ea v\u00ea seu rosto? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1913414\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Oval\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1913414\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1913414]\"\n                                value=\"Oval\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Oval\"\n                            >\n                    Oval                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt2070963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Quadrado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt2070963\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt2070963]\"\n                                value=\"Quadrado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Quadrado\"\n                            >\n                    Quadrado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1418703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Redondo\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1418703\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1418703]\"\n                                value=\"Redondo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Redondo\"\n                            >\n                    Redondo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1337689\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Testa alta\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1337689\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1337689]\"\n                                value=\"Testa alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Testa alta\"\n                            >\n                    Testa alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1424835\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Testa enrugada\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1424835\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1424835]\"\n                                value=\"Testa enrugada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Testa enrugada\"\n                            >\n                    Testa enrugada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1392540\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Orelhas normais\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1392540\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1392540]\"\n                                value=\"Orelhas normais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Orelhas normais\"\n                            >\n                    Orelhas normais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1571283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Orelhas grandes\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1571283\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1571283]\"\n                                value=\"Orelhas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Orelhas grandes\"\n                            >\n                    Orelhas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt2053363\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Queixo recuado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt2053363\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt2053363]\"\n                                value=\"Queixo recuado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Queixo recuado\"\n                            >\n                    Queixo recuado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1918847\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Queixo quadrado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1918847\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1918847]\"\n                                value=\"Queixo quadrado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Queixo quadrado\"\n                            >\n                    Queixo quadrado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1279022\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Bochechas normais\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1279022\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1279022]\"\n                                value=\"Bochechas normais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Bochechas normais\"\n                            >\n                    Bochechas normais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1514673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Bochechas grandes\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1514673\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1514673]\"\n                                value=\"Bochechas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Bochechas grandes\"\n                            >\n                    Bochechas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1548620\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Forma de cora\u00e7\u00e3o\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1548620\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1548620]\"\n                                value=\"Forma de cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Forma de cora\u00e7\u00e3o\"\n                            >\n                    Forma de cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1462428\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Dorma de diamante\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1462428\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1462428]\"\n                                value=\"Dorma de diamante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Dorma de diamante\"\n                            >\n                    Dorma de diamante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_1_opt1891411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_1\" data-parsley-multiple=\"fld_6779368_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_1_opt1891411\"\n                                class=\"fld_6779368_1 option-required\"\n                                name=\"fld_6779368[opt1891411]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9781446_1\" data-field-id=\"fld_9781446_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-55\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8989705\" class=\"form-group\" id=\"fld_8989705_1-wrap\">\r\n\t<label id=\"fld_8989705Label\" for=\"fld_8989705_1\" class=\"control-label\">Como voc\u00ea v\u00ea sua express\u00e3o facial? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1154354\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Feliz\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1154354\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1154354]\"\n                                value=\"Feliz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Feliz\"\n                            >\n                    Feliz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1709908\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Sorridente\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1709908\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1709908]\"\n                                value=\"Sorridente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Sorridente\"\n                            >\n                    Sorridente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1542907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Orgulhosa\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1542907\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1542907]\"\n                                value=\"Orgulhosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Orgulhosa\"\n                            >\n                    Orgulhosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt2011870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Assustada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt2011870\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt2011870]\"\n                                value=\"Assustada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Assustada\"\n                            >\n                    Assustada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1988412\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Feroz\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1988412\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1988412]\"\n                                value=\"Feroz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Feroz\"\n                            >\n                    Feroz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1616685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Raivosa\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1616685\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1616685]\"\n                                value=\"Raivosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Raivosa\"\n                            >\n                    Raivosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1992369\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Fria\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1992369\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1992369]\"\n                                value=\"Fria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Fria\"\n                            >\n                    Fria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt2060092\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Cansada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt2060092\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt2060092]\"\n                                value=\"Cansada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Cansada\"\n                            >\n                    Cansada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1268643\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Suspeita\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1268643\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1268643]\"\n                                value=\"Suspeita\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Suspeita\"\n                            >\n                    Suspeita                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1347771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Preocupada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1347771\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1347771]\"\n                                value=\"Preocupada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Preocupada\"\n                            >\n                    Preocupada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_1_opt1194404\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_1\" data-parsley-multiple=\"fld_8989705_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_1_opt1194404\"\n                                class=\"fld_8989705_1 option-required\"\n                                name=\"fld_8989705[opt1194404]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7632005_1\" data-field-id=\"fld_7632005_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9441006\" class=\"form-group\" id=\"fld_9441006_1-wrap\">\r\n<label id=\"fld_9441006Label\" for=\"fld_9441006_1\" class=\"control-label\">Qual a cor dos seus olhos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Verde\" for=\"fld_9441006_1_opt1271878\"><input type=\"radio\" id=\"fld_9441006_1_opt1271878\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Verde\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Verde\" \/>\n\t\t\tVerde\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Azul\" for=\"fld_9441006_1_opt1399360\"><input type=\"radio\" id=\"fld_9441006_1_opt1399360\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Azul\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Azul\" \/>\n\t\t\tAzul\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Castanho claro\" for=\"fld_9441006_1_opt1928196\"><input type=\"radio\" id=\"fld_9441006_1_opt1928196\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Castanho claro\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Castanho claro\" \/>\n\t\t\tCastanho claro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Castanho escuro\" for=\"fld_9441006_1_opt1260479\"><input type=\"radio\" id=\"fld_9441006_1_opt1260479\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Castanho escuro\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Castanho escuro\" \/>\n\t\t\tCastanho escuro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Preto\" for=\"fld_9441006_1_opt1431839\"><input type=\"radio\" id=\"fld_9441006_1_opt1431839\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Preto\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Preto\" \/>\n\t\t\tPreto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Vermelho (Cores raras)\" for=\"fld_9441006_1_opt1631248\"><input type=\"radio\" id=\"fld_9441006_1_opt1631248\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Vermelho (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Vermelho (Cores raras)\" \/>\n\t\t\tVermelho (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Rosa (Cores raras)\" for=\"fld_9441006_1_opt1400799\"><input type=\"radio\" id=\"fld_9441006_1_opt1400799\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Rosa (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Rosa (Cores raras)\" \/>\n\t\t\tRosa (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Violeta (Cores raras)\" for=\"fld_9441006_1_opt1953019\"><input type=\"radio\" id=\"fld_9441006_1_opt1953019\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"Violeta (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"Violeta (Cores raras)\" \/>\n\t\t\tVioleta (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"\u00c2mbar (Cores raras)\" for=\"fld_9441006_1_opt1253226\"><input type=\"radio\" id=\"fld_9441006_1_opt1253226\" data-field=\"fld_9441006\" class=\"fld_9441006_1 option-required\" name=\"fld_9441006\" value=\"\u00c2mbar (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_1\" data-type=\"radio\" data-calc-value=\"\u00c2mbar (Cores raras)\" \/>\n\t\t\t\u00c2mbar (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_1-row-56\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7468061\" class=\"form-group\" id=\"fld_7468061_1-wrap\">\r\n<label id=\"fld_7468061Label\" for=\"fld_7468061_1\" class=\"control-label\">Qual a cor natural do seu cabelo? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Preto\" for=\"fld_7468061_1_opt1691168\"><input type=\"radio\" id=\"fld_7468061_1_opt1691168\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Preto\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Preto\" \/>\n\t\t\tPreto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Marrom\" for=\"fld_7468061_1_opt1814183\"><input type=\"radio\" id=\"fld_7468061_1_opt1814183\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Marrom\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Marrom\" \/>\n\t\t\tMarrom\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Loiro\" for=\"fld_7468061_1_opt1852592\"><input type=\"radio\" id=\"fld_7468061_1_opt1852592\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Loiro\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Loiro\" \/>\n\t\t\tLoiro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ruivo\" for=\"fld_7468061_1_opt1163534\"><input type=\"radio\" id=\"fld_7468061_1_opt1163534\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Ruivo\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Ruivo\" \/>\n\t\t\tRuivo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Cinza\" for=\"fld_7468061_1_opt1227501\"><input type=\"radio\" id=\"fld_7468061_1_opt1227501\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Cinza\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Cinza\" \/>\n\t\t\tCinza\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Branco (albino)\" for=\"fld_7468061_1_opt1278283\"><input type=\"radio\" id=\"fld_7468061_1_opt1278283\" data-field=\"fld_7468061\" class=\"fld_7468061_1 option-required\" name=\"fld_7468061\" value=\"Branco (albino)\"   required=\"required\" data-radio-field=\"fld_7468061_1\" data-type=\"radio\" data-calc-value=\"Branco (albino)\" \/>\n\t\t\tBranco (albino)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF603020f491e20_1-row-57\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_1382587\" class=\"form-group\" id=\"fld_1382587_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_1382587\" id=\"fld_1382587_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_1382587\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_1382587\" id=\"fld_1382587_1_btn\" value=\"\" data-field=\"fld_1382587\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9153598\" class=\"form-group\" id=\"fld_9153598_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_9153598\" id=\"fld_9153598_1\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_9153598\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_9153598\" id=\"fld_9153598_1_btn\" value=\"\" data-field=\"fld_9153598\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_2883934\" class=\"form-group\" id=\"fld_2883934_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_2883934\" id=\"fld_2883934_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_2883934\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_2883934\" id=\"fld_2883934_1_btn\" value=\"\" data-field=\"fld_2883934\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_1_pg_11\" data-formpage=\"11\" role=\"region\" aria-labelledby=\"breadcrumb_1_pg_11\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_1-row-58\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_9768910\" class=\"form-group\" id=\"fld_9768910_1-wrap\">\r\n\t<label id=\"fld_9768910Label\" for=\"fld_9768910_1\" class=\"control-label\">Descreva seu car\u00e1ter <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1667960\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Afetuso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1667960\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1667960]\"\n                                value=\"Afetuso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Afetuso\"\n                            >\n                    Afetuso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1142992\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Alegre\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1142992\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1142992]\"\n                                value=\"Alegre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Alegre\"\n                            >\n                    Alegre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1923804\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Ambicioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1923804\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1923804]\"\n                                value=\"Ambicioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Ambicioso\"\n                            >\n                    Ambicioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1498788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Ansioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1498788\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1498788]\"\n                                value=\"Ansioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Ansioso\"\n                            >\n                    Ansioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1266952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Argumentativo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1266952\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1266952]\"\n                                value=\"Argumentativo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Argumentativo\"\n                            >\n                    Argumentativo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1633100\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Bobo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1633100\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1633100]\"\n                                value=\"Bobo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Bobo\"\n                            >\n                    Bobo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1799730\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Briguento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1799730\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1799730]\"\n                                value=\"Briguento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Briguento\"\n                            >\n                    Briguento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1592225\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Cantor\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1592225\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1592225]\"\n                                value=\"Cantor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Cantor\"\n                            >\n                    Cantor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1200981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Caprichoso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1200981\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1200981]\"\n                                value=\"Caprichoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Caprichoso\"\n                            >\n                    Caprichoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1650360\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Ciumento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1650360\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1650360]\"\n                                value=\"Ciumento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Ciumento\"\n                            >\n                    Ciumento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1648755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Compulsivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1648755\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1648755]\"\n                                value=\"Compulsivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Compulsivo\"\n                            >\n                    Compulsivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1514495\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Confuso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1514495\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1514495]\"\n                                value=\"Confuso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Confuso\"\n                            >\n                    Confuso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1665475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Desanimado\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1665475\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1665475]\"\n                                value=\"Desanimado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Desanimado\"\n                            >\n                    Desanimado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt2010409\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Destrutivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt2010409\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt2010409]\"\n                                value=\"Destrutivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Destrutivo\"\n                            >\n                    Destrutivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1260129\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Distraido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1260129\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1260129]\"\n                                value=\"Distraido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Distraido\"\n                            >\n                    Distraido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1401824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Ditatorial\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1401824\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1401824]\"\n                                value=\"Ditatorial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Ditatorial\"\n                            >\n                    Ditatorial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1491921\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Doce\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1491921\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1491921]\"\n                                value=\"Doce\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Doce\"\n                            >\n                    Doce                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1479011\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Dominador\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1479011\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1479011]\"\n                                value=\"Dominador\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Dominador\"\n                            >\n                    Dominador                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1415494\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Exigente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1415494\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1415494]\"\n                                value=\"Exigente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Exigente\"\n                            >\n                    Exigente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1986502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Fantasioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1986502\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1986502]\"\n                                value=\"Fantasioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Fantasioso\"\n                            >\n                    Fantasioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1224693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Feliz\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1224693\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1224693]\"\n                                value=\"Feliz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Feliz\"\n                            >\n                    Feliz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1749307\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Filos\u00f3fico\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1749307\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1749307]\"\n                                value=\"Filos\u00f3fico\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Filos\u00f3fico\"\n                            >\n                    Filos\u00f3fico                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1936815\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Generoso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1936815\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1936815]\"\n                                value=\"Generoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Generoso\"\n                            >\n                    Generoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt2046031\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Gentil\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt2046031\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt2046031]\"\n                                value=\"Gentil\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Gentil\"\n                            >\n                    Gentil                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1410045\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Hiperativo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1410045\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1410045]\"\n                                value=\"Hiperativo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Hiperativo\"\n                            >\n                    Hiperativo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1543408\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Impaciente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1543408\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1543408]\"\n                                value=\"Impaciente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Impaciente\"\n                            >\n                    Impaciente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1576081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Impulsivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1576081\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1576081]\"\n                                value=\"Impulsivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Impulsivo\"\n                            >\n                    Impulsivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1659699\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Indiferente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1659699\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1659699]\"\n                                value=\"Indiferente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Indiferente\"\n                            >\n                    Indiferente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1845939\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Insatisfeito\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1845939\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1845939]\"\n                                value=\"Insatisfeito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Insatisfeito\"\n                            >\n                    Insatisfeito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1565623\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Irritado\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1565623\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1565623]\"\n                                value=\"Irritado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Irritado\"\n                            >\n                    Irritado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1457241\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"L\u00edder\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1457241\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1457241]\"\n                                value=\"L\u00edder\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"L\u00edder\"\n                            >\n                    L\u00edder                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1418688\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Meticuloso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1418688\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1418688]\"\n                                value=\"Meticuloso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Meticuloso\"\n                            >\n                    Meticuloso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1115289\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Paradoxal\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1115289\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1115289]\"\n                                value=\"Paradoxal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Paradoxal\"\n                            >\n                    Paradoxal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1230440\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Passivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1230440\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1230440]\"\n                                value=\"Passivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Passivo\"\n                            >\n                    Passivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1403429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Rude\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1403429\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1403429]\"\n                                value=\"Rude\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Rude\"\n                            >\n                    Rude                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1267122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Sedento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1267122\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1267122]\"\n                                value=\"Sedento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Sedento\"\n                            >\n                    Sedento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1428870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"S\u00e9rio\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1428870\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1428870]\"\n                                value=\"S\u00e9rio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"S\u00e9rio\"\n                            >\n                    S\u00e9rio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1833381\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Tagarela\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1833381\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1833381]\"\n                                value=\"Tagarela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Tagarela\"\n                            >\n                    Tagarela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1264997\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"T\u00edmido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1264997\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1264997]\"\n                                value=\"T\u00edmido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"T\u00edmido\"\n                            >\n                    T\u00edmido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt2034489\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Triste\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt2034489\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt2034489]\"\n                                value=\"Triste\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Triste\"\n                            >\n                    Triste                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1915932\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"A vida pelo trabalho\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1915932\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1915932]\"\n                                value=\"A vida pelo trabalho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"A vida pelo trabalho\"\n                            >\n                    A vida pelo trabalho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1786557\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Aliviado pelo choro\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1786557\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1786557]\"\n                                value=\"Aliviado pelo choro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Aliviado pelo choro\"\n                            >\n                    Aliviado pelo choro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1198685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Amante dos animais\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1198685\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1198685]\"\n                                value=\"Amante dos animais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Amante dos animais\"\n                            >\n                    Amante dos animais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1563818\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Aprendiz lento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1563818\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1563818]\"\n                                value=\"Aprendiz lento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Aprendiz lento\"\n                            >\n                    Aprendiz lento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1273434\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"As l\u00e1grimas com a m\u00fasica\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1273434\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1273434]\"\n                                value=\"As l\u00e1grimas com a m\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"As l\u00e1grimas com a m\u00fasica\"\n                            >\n                    As l\u00e1grimas com a m\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1920506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Facilmente ofendido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1920506\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1920506]\"\n                                value=\"Facilmente ofendido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Facilmente ofendido\"\n                            >\n                    Facilmente ofendido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1372972\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Gosta de estar s\u00f3\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1372972\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1372972]\"\n                                value=\"Gosta de estar s\u00f3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Gosta de estar s\u00f3\"\n                            >\n                    Gosta de estar s\u00f3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1843270\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Medo de morrer\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1843270\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1843270]\"\n                                value=\"Medo de morrer\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Medo de morrer\"\n                            >\n                    Medo de morrer                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1645860\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Medo de dentista\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1645860\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1645860]\"\n                                value=\"Medo de dentista\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Medo de dentista\"\n                            >\n                    Medo de dentista                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1290815\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Obcecado com a religi\u00e3o\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1290815\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1290815]\"\n                                value=\"Obcecado com a religi\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Obcecado com a religi\u00e3o\"\n                            >\n                    Obcecado com a religi\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1427690\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Pior no calor\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1427690\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1427690]\"\n                                value=\"Pior no calor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Pior no calor\"\n                            >\n                    Pior no calor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1591419\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Pior no tempo seco\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1591419\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1591419]\"\n                                value=\"Pior no tempo seco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Pior no tempo seco\"\n                            >\n                    Pior no tempo seco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1974093\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"R\u00e1pido em fazer as coisas\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1974093\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1974093]\"\n                                value=\"R\u00e1pido em fazer as coisas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"R\u00e1pido em fazer as coisas\"\n                            >\n                    R\u00e1pido em fazer as coisas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1655123\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edvel ao ru\u00eddo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1655123\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1655123]\"\n                                value=\"Sens\u00edvel ao ru\u00eddo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Sens\u00edvel ao ru\u00eddo\"\n                            >\n                    Sens\u00edvel ao ru\u00eddo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1341190\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Um valent\u00e3o\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1341190\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1341190]\"\n                                value=\"Um valent\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Um valent\u00e3o\"\n                            >\n                    Um valent\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1533346\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Uma pessoa ao ar livre\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1533346\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1533346]\"\n                                value=\"Uma pessoa ao ar livre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Uma pessoa ao ar livre\"\n                            >\n                    Uma pessoa ao ar livre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1998390\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Verbalmente abusivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1998390\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1998390]\"\n                                value=\"Verbalmente abusivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Verbalmente abusivo\"\n                            >\n                    Verbalmente abusivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_1_opt1895088\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_1\" data-parsley-multiple=\"fld_9768910_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_1_opt1895088\"\n                                class=\"fld_9768910_1 option-required\"\n                                name=\"fld_9768910[opt1895088]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_411163_1\" data-field-id=\"fld_411163_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3099297\" class=\"form-group\" id=\"fld_3099297_1-wrap\">\r\n\t<label id=\"fld_3099297Label\" for=\"fld_3099297_1\" class=\"control-label\">O que ou quem voc\u00ea n\u00e3o gosta? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1901180\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Marido\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1901180\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1901180]\"\n                                value=\"Marido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Marido\"\n                            >\n                    Marido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1420068\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Esposo(a)\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1420068\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1420068]\"\n                                value=\"Esposo(a)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Esposo(a)\"\n                            >\n                    Esposo(a)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1989907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1989907\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1989907]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1969583\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Amigos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1969583\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1969583]\"\n                                value=\"Amigos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Amigos\"\n                            >\n                    Amigos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1238716\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Estranhos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1238716\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1238716]\"\n                                value=\"Estranhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Estranhos\"\n                            >\n                    Estranhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1718857\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Um membro da fam\u00edlia\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1718857\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1718857]\"\n                                value=\"Um membro da fam\u00edlia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Um membro da fam\u00edlia\"\n                            >\n                    Um membro da fam\u00edlia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1204141\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Empresa\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1204141\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1204141]\"\n                                value=\"Empresa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Empresa\"\n                            >\n                    Empresa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt2079215\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Trabalho escrito\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt2079215\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt2079215]\"\n                                value=\"Trabalho escrito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Trabalho escrito\"\n                            >\n                    Trabalho escrito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1462652\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Exerc\u00edcio\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1462652\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1462652]\"\n                                value=\"Exerc\u00edcio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Exerc\u00edcio\"\n                            >\n                    Exerc\u00edcio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1252296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Exerc\u00edcio mental\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1252296\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1252296]\"\n                                value=\"Exerc\u00edcio mental\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Exerc\u00edcio mental\"\n                            >\n                    Exerc\u00edcio mental                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1297993\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"M\u00fasica\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1297993\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1297993]\"\n                                value=\"M\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"M\u00fasica\"\n                            >\n                    M\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1414568\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Ru\u00eddo\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1414568\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1414568]\"\n                                value=\"Ru\u00eddo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Ru\u00eddo\"\n                            >\n                    Ru\u00eddo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1961247\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Banho\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1961247\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1961247]\"\n                                value=\"Banho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Banho\"\n                            >\n                    Banho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt2070552\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Odores\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt2070552\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt2070552]\"\n                                value=\"Odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Odores\"\n                            >\n                    Odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1174423\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Luz solar\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1174423\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1174423]\"\n                                value=\"Luz solar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Luz solar\"\n                            >\n                    Luz solar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1902952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Janelas fechadas\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1902952\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1902952]\"\n                                value=\"Janelas fechadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Janelas fechadas\"\n                            >\n                    Janelas fechadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1908593\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Ficar no interior\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1908593\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1908593]\"\n                                value=\"Ficar no interior\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Ficar no interior\"\n                            >\n                    Ficar no interior                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt2091788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Roupas apertadas\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt2091788\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt2091788]\"\n                                value=\"Roupas apertadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Roupas apertadas\"\n                            >\n                    Roupas apertadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1443073\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Ser contrariado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1443073\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1443073]\"\n                                value=\"Ser contrariado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Ser contrariado\"\n                            >\n                    Ser contrariado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt2087621\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Ser consolado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt2087621\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt2087621]\"\n                                value=\"Ser consolado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Ser consolado\"\n                            >\n                    Ser consolado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1440500\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Estar errado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1440500\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1440500]\"\n                                value=\"Estar errado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Estar errado\"\n                            >\n                    Estar errado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1174638\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es \"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1174638\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1174638]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es \"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_1_opt1632862\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_1\" data-parsley-multiple=\"fld_3099297_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_1_opt1632862\"\n                                class=\"fld_3099297_1 option-required\"\n                                name=\"fld_3099297[opt1632862]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_846866_1\" data-field-id=\"fld_846866_1\"><\/span><div data-field-wrapper=\"fld_5604272\" class=\"form-group\" id=\"fld_5604272_1-wrap\">\r\n\t<label id=\"fld_5604272Label\" for=\"fld_5604272_1\" class=\"control-label\">O que voc\u00ea mais teme? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1910465\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Afei\u00e7\u00e3o\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1910465\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1910465]\"\n                                value=\"Afei\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Afei\u00e7\u00e3o\"\n                            >\n                    Afei\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1080636\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Altura\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1080636\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1080636]\"\n                                value=\"Altura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Altura\"\n                            >\n                    Altura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt2011740\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Assaltantes\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt2011740\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt2011740]\"\n                                value=\"Assaltantes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Assaltantes\"\n                            >\n                    Assaltantes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1796603\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Cobras\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1796603\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1796603]\"\n                                value=\"Cobras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Cobras\"\n                            >\n                    Cobras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1973113\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Contradi\u00e7\u00e3o\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1973113\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1973113]\"\n                                value=\"Contradi\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Contradi\u00e7\u00e3o\"\n                            >\n                    Contradi\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1668994\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Dirigir\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1668994\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1668994]\"\n                                value=\"Dirigir\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Dirigir\"\n                            >\n                    Dirigir                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1539264\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Doen\u00e7a\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1539264\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1539264]\"\n                                value=\"Doen\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Doen\u00e7a\"\n                            >\n                    Doen\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1577692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Escuro\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1577692\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1577692]\"\n                                value=\"Escuro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Escuro\"\n                            >\n                    Escuro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1413731\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Estar sozinho\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1413731\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1413731]\"\n                                value=\"Estar sozinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Estar sozinho\"\n                            >\n                    Estar sozinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt2006274\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Falhar\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt2006274\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt2006274]\"\n                                value=\"Falhar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Falhar\"\n                            >\n                    Falhar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1917742\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Morte\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1917742\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1917742]\"\n                                value=\"Morte\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Morte\"\n                            >\n                    Morte                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1317228\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Multid\u00f5es\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1317228\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1317228]\"\n                                value=\"Multid\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Multid\u00f5es\"\n                            >\n                    Multid\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1262287\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Opini\u00e3o dos outros\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1262287\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1262287]\"\n                                value=\"Opini\u00e3o dos outros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Opini\u00e3o dos outros\"\n                            >\n                    Opini\u00e3o dos outros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1887475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Ser tocado\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1887475\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1887475]\"\n                                value=\"Ser tocado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Ser tocado\"\n                            >\n                    Ser tocado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1752389\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Trovoadas\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1752389\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1752389]\"\n                                value=\"Trovoadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Trovoadas\"\n                            >\n                    Trovoadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1562011\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1562011\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1562011]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_1_opt1666762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_1\" data-parsley-multiple=\"fld_5604272_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_1_opt1666762\"\n                                class=\"fld_5604272_1 option-required\"\n                                name=\"fld_5604272[opt1666762]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5703829_1\" data-field-id=\"fld_5703829_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-59\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6042275\" class=\"form-group\" id=\"fld_6042275_1-wrap\">\r\n\t<label id=\"fld_6042275Label\" for=\"fld_6042275_1\" class=\"control-label\">Como \u00e9 o seu sono? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1892984\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Normal\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1892984\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1892984]\"\n                                value=\"Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Normal\"\n                            >\n                    Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1686638\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Profundo\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1686638\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1686638]\"\n                                value=\"Profundo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Profundo\"\n                            >\n                    Profundo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1790276\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Inquieto\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1790276\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1790276]\"\n                                value=\"Inquieto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Inquieto\"\n                            >\n                    Inquieto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1515578\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Interrompido\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1515578\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1515578]\"\n                                value=\"Interrompido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Interrompido\"\n                            >\n                    Interrompido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1644411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Perturbado\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1644411\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1644411]\"\n                                value=\"Perturbado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Perturbado\"\n                            >\n                    Perturbado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1822189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Curto\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1822189\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1822189]\"\n                                value=\"Curto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Curto\"\n                            >\n                    Curto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1923201\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Ins\u00f4nia\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1923201\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1923201]\"\n                                value=\"Ins\u00f4nia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Ins\u00f4nia\"\n                            >\n                    Ins\u00f4nia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1719637\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Apneia do sono\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1719637\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1719637]\"\n                                value=\"Apneia do sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Apneia do sono\"\n                            >\n                    Apneia do sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt2039008\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Fica com sono em p\u00e9\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt2039008\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt2039008]\"\n                                value=\"Fica com sono em p\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Fica com sono em p\u00e9\"\n                            >\n                    Fica com sono em p\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1567532\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Mau humor quando acorda\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1567532\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1567532]\"\n                                value=\"Mau humor quando acorda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Mau humor quando acorda\"\n                            >\n                    Mau humor quando acorda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1760354\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Evita dormir sobre o lado direito da cama\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1760354\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1760354]\"\n                                value=\"Evita dormir sobre o lado direito da cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Evita dormir sobre o lado direito da cama\"\n                            >\n                    Evita dormir sobre o lado direito da cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1782487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Evita dormir sobre o lado esquerdo da cama\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1782487\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1782487]\"\n                                value=\"Evita dormir sobre o lado esquerdo da cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Evita dormir sobre o lado esquerdo da cama\"\n                            >\n                    Evita dormir sobre o lado esquerdo da cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1144693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Terrores noturnos\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1144693\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1144693]\"\n                                value=\"Terrores noturnos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Terrores noturnos\"\n                            >\n                    Terrores noturnos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_1_opt1975442\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_1\" data-parsley-multiple=\"fld_6042275_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_1_opt1975442\"\n                                class=\"fld_6042275_1 option-required\"\n                                name=\"fld_6042275[opt1975442]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1642058_1\" data-field-id=\"fld_1642058_1\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_8328657\" class=\"form-group\" id=\"fld_8328657_1-wrap\">\r\n\t<label id=\"fld_8328657Label\" for=\"fld_8328657_1\" class=\"control-label\">Sintomas Emocionais <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt2072884\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Alucina\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt2072884\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt2072884]\"\n                                value=\"Alucina\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Alucina\u00e7\u00e3o\"\n                            >\n                    Alucina\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1768646\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Ansiedade\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1768646\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1768646]\"\n                                value=\"Ansiedade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Ansiedade\"\n                            >\n                    Ansiedade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1450071\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o a crian\u00e7as\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1450071\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1450071]\"\n                                value=\"Avers\u00e3o a crian\u00e7as\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Avers\u00e3o a crian\u00e7as\"\n                            >\n                    Avers\u00e3o a crian\u00e7as                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1946535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o ao mental\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1946535\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1946535]\"\n                                value=\"Avers\u00e3o ao mental\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Avers\u00e3o ao mental\"\n                            >\n                    Avers\u00e3o ao mental                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1166827\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o ao trabalho\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1166827\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1166827]\"\n                                value=\"Avers\u00e3o ao trabalho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Avers\u00e3o ao trabalho\"\n                            >\n                    Avers\u00e3o ao trabalho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1072907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Confus\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1072907\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1072907]\"\n                                value=\"Confus\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Confus\u00e3o\"\n                            >\n                    Confus\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1488446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Cora\u00e7\u00e3o partido\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1488446\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1488446]\"\n                                value=\"Cora\u00e7\u00e3o partido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Cora\u00e7\u00e3o partido\"\n                            >\n                    Cora\u00e7\u00e3o partido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt2053478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Depress\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt2053478\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt2053478]\"\n                                value=\"Depress\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Depress\u00e3o\"\n                            >\n                    Depress\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1781550\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Desejo de aten\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1781550\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1781550]\"\n                                value=\"Desejo de aten\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Desejo de aten\u00e7\u00e3o\"\n                            >\n                    Desejo de aten\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1226081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de aprendizagem\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1226081\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1226081]\"\n                                value=\"Dificuldade de aprendizagem\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Dificuldade de aprendizagem\"\n                            >\n                    Dificuldade de aprendizagem                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1802287\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Falta de concentra\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1802287\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1802287]\"\n                                value=\"Falta de concentra\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Falta de concentra\u00e7\u00e3o\"\n                            >\n                    Falta de concentra\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1699692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Instabilidade emocional\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1699692\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1699692]\"\n                                value=\"Instabilidade emocional\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Instabilidade emocional\"\n                            >\n                    Instabilidade emocional                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1940065\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Manias ou TOC\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1940065\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1940065]\"\n                                value=\"Manias ou TOC\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Manias ou TOC\"\n                            >\n                    Manias ou TOC                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1693115\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Mem\u00f3ria fraca\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1693115\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1693115]\"\n                                value=\"Mem\u00f3ria fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Mem\u00f3ria fraca\"\n                            >\n                    Mem\u00f3ria fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1213400\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Raiva\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1213400\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1213400]\"\n                                value=\"Raiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Raiva\"\n                            >\n                    Raiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1596558\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Repuls\u00e3o para o sexo\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1596558\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1596558]\"\n                                value=\"Repuls\u00e3o para o sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Repuls\u00e3o para o sexo\"\n                            >\n                    Repuls\u00e3o para o sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1847615\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Tend\u00eancias suicidas\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1847615\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1847615]\"\n                                value=\"Tend\u00eancias suicidas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Tend\u00eancias suicidas\"\n                            >\n                    Tend\u00eancias suicidas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1210235\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1210235\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1210235]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_1_opt1173020\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_1\" data-parsley-multiple=\"fld_8328657_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_1_opt1173020\"\n                                class=\"fld_8328657_1 option-required\"\n                                name=\"fld_8328657[opt1173020]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2102016_1\" data-field-id=\"fld_2102016_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-60\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8454960\" class=\"form-group\" id=\"fld_8454960_1-wrap\">\r\n\t<label id=\"fld_8454960Label\" for=\"fld_8454960_1\" class=\"control-label\">Sintomas sexuais <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1741551\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Apetite sexual excessivo\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1741551\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1741551]\"\n                                value=\"Apetite sexual excessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Apetite sexual excessivo\"\n                            >\n                    Apetite sexual excessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1970356\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Sexualmente insatisfeito\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1970356\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1970356]\"\n                                value=\"Sexualmente insatisfeito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Sexualmente insatisfeito\"\n                            >\n                    Sexualmente insatisfeito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1991164\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Coito dif\u00edcil\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1991164\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1991164]\"\n                                value=\"Coito dif\u00edcil\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Coito dif\u00edcil\"\n                            >\n                    Coito dif\u00edcil                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1697506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Disfun\u00e7\u00e3o sexual\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1697506\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1697506]\"\n                                value=\"Disfun\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Disfun\u00e7\u00e3o sexual\"\n                            >\n                    Disfun\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1981920\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Repuls\u00e3o para sexo\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1981920\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1981920]\"\n                                value=\"Repuls\u00e3o para sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Repuls\u00e3o para sexo\"\n                            >\n                    Repuls\u00e3o para sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1315807\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1315807\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1315807]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_1_opt1647391\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_1\" data-parsley-multiple=\"fld_8454960_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_1_opt1647391\"\n                                class=\"fld_8454960_1 option-required\"\n                                name=\"fld_8454960[opt1647391]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7252825_1\" data-field-id=\"fld_7252825_1\"><\/span><\/div><\/div><div id=\"CF603020f491e20_1-row-61\"  class=\"row  last_row\"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_3088417\" class=\"form-group\" id=\"fld_3088417_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_3088417\" id=\"fld_3088417_1\" value=\"P\u00e1gina Anterior\" data-field=\"fld_3088417\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_3088417\" id=\"fld_3088417_1_btn\" value=\"\" data-field=\"fld_3088417\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6344075\" class=\"form-group\" id=\"fld_6344075_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_6344075\" id=\"fld_6344075_1\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_6344075\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_6344075\" id=\"fld_6344075_1_btn\" value=\"\" data-field=\"fld_6344075\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8429954\" class=\"form-group\" id=\"fld_8429954_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_8429954\" id=\"fld_8429954_1\" value=\"Enviar Formul\u00e1rio\" data-field=\"fld_8429954\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_8429954\" id=\"fld_8429954_1_btn\" value=\"\" data-field=\"fld_8429954\"  \/>\n<\/div><\/div><\/div><\/form>\r\n<\/div>\r\n<script type=\"text\/javascript\">\r\nif( typeof caldera_conditionals === \"undefined\" ){ var caldera_conditionals = {}; }caldera_conditionals.CF603020f491e20_1 = {\"fld_9442215_1\":{\"type\":\"show\",\"group\":{\"rw_skcba\":{\"cl_btaercssd\":{\"id\":\"cl_btaercssd\",\"field\":\"fld_1574495\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_skcba\",\"label\":\"Outro\"}}}},\"fld_7633772_1\":{\"type\":\"show\",\"group\":{\"rw_civeuhkrn\":{\"cl_hciyzdu\":{\"id\":\"cl_hciyzdu\",\"field\":\"fld_3473230\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_civeuhkrn\",\"label\":\"Outro\"}}}},\"fld_783295_1\":{\"type\":\"show\",\"group\":{\"rw_hsmptnce\":{\"cl_myntzmpf\":{\"id\":\"cl_myntzmpf\",\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_hsmptnce\",\"label\":\"Feminino\"}}}},\"fld_1576420_1\":{\"type\":\"show\",\"group\":{\"rw_xmrlvpc\":{\"cl_trghfltd\":{\"id\":\"cl_trghfltd\",\"field\":\"fld_8364991\",\"value\":\"Sim\",\"compare\":\"is\",\"parent\":\"rw_xmrlvpc\",\"label\":\"Sim\"}}}},\"fld_9024547_1\":{\"type\":\"show\",\"group\":{\"rw_inxbbckdd\":{\"cl_ytpjcjijxi\":{\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_inxbbckdd\",\"id\":\"cl_ytpjcjijxi\",\"label\":\"Feminino\"},\"cl_rqriwfefxw\":{\"field\":\"fld_8364991\",\"value\":\"Sim\",\"compare\":\"is\",\"parent\":\"rw_inxbbckdd\",\"id\":\"cl_rqriwfefxw\",\"label\":\"Sim\"}}}},\"fld_3885880_1\":{\"type\":\"show\",\"group\":{\"rw_mtzxthxaz\":{\"cl_yzyxua\":{\"id\":\"cl_yzyxua\",\"field\":\"fld_7159025\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_mtzxthxaz\",\"label\":\"Outro\"}}}},\"fld_6650295_1\":{\"type\":\"show\",\"group\":{\"rw_wgisij\":{\"cl_ctimru\":{\"id\":\"cl_ctimru\",\"field\":\"fld_6367522\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_wgisij\",\"label\":\"Outro\"}}}},\"fld_1530349_1\":{\"type\":\"hide\",\"group\":{\"rw_phnvnle\":{\"cl_bvhlrdd\":{\"id\":\"cl_bvhlrdd\",\"field\":\"fld_8952750\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_phnvnle\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_3043002_1\":{\"type\":\"hide\",\"group\":{\"rw_movycbfae\":{\"cl_gfhffyp\":{\"id\":\"cl_gfhffyp\",\"field\":\"fld_5652515\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_movycbfae\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_1619118_1\":{\"type\":\"hide\",\"group\":{\"rw_bqbajvdnuto\":{\"cl_heqptz\":{\"id\":\"cl_heqptz\",\"field\":\"fld_4659334\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_bqbajvdnuto\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_7494269_1\":{\"type\":\"show\",\"group\":{\"rw_pkquiuby\":{\"cl_nhsgxs\":{\"id\":\"cl_nhsgxs\",\"field\":\"fld_8514796\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_pkquiuby\",\"label\":\"Outro\"}}}},\"fld_6094755_1\":{\"type\":\"show\",\"group\":{\"rw_avmvvffhv\":{\"cl_oyljxzgj\":{\"id\":\"cl_oyljxzgj\",\"field\":\"fld_7513570\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_avmvvffhv\",\"label\":\"Outro\"}}}},\"fld_2575749_1\":{\"type\":\"hide\",\"group\":{\"rw_vllsbdzi\":{\"cl_lzltlmc\":{\"id\":\"cl_lzltlmc\",\"field\":\"fld_5873470\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_vllsbdzi\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_7520435_1\":{\"type\":\"show\",\"group\":{\"rw_lvfuepfxv\":{\"cl_xelleremg\":{\"id\":\"cl_xelleremg\",\"field\":\"fld_5873470\",\"value\":\"Cigarro, charuto ou cachimbo\",\"compare\":\"is\",\"parent\":\"rw_lvfuepfxv\",\"label\":\"Cigarro, charuto ou cachimbo\"}}}},\"fld_977328_1\":{\"type\":\"show\",\"group\":{\"rw_qxfgbzkca\":{\"cl_pvchfosgg\":{\"id\":\"cl_pvchfosgg\",\"field\":\"fld_544334\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qxfgbzkca\",\"label\":\"Outro\"}}}},\"fld_2985878_1\":{\"type\":\"show\",\"group\":{\"rw_cixnmkuls\":{\"cl_gglonozmo\":{\"id\":\"cl_gglonozmo\",\"field\":\"fld_3226139\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_cixnmkuls\",\"label\":\"Outro\"}}}},\"fld_950222_1\":{\"type\":\"hide\",\"group\":{\"rw_dclqgp\":{\"cl_lfgftd\":{\"id\":\"cl_lfgftd\",\"field\":\"fld_6437431\",\"value\":\"N\\u00e3o, nunca ingeri\",\"compare\":\"is\",\"parent\":\"rw_dclqgp\",\"label\":\"N\\u00e3o, nunca ingeri\"}}}},\"fld_8312371_1\":{\"type\":\"show\",\"group\":{\"rw_gyrgxqsvw\":{\"cl_zehtok\":{\"id\":\"cl_zehtok\",\"field\":\"fld_5437915\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_gyrgxqsvw\",\"label\":\"Outro\"}}}},\"fld_804883_1\":{\"type\":\"show\",\"group\":{\"rw_buhqkcfq\":{\"cl_bhxtdzvtw\":{\"id\":\"cl_bhxtdzvtw\",\"field\":\"fld_2165263\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_buhqkcfq\",\"label\":\"Outro\"}}}},\"fld_821839_1\":{\"type\":\"show\",\"group\":{\"rw_mrbnokfco\":{\"cl_shdlwau\":{\"id\":\"cl_shdlwau\",\"field\":\"fld_3091293\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_mrbnokfco\",\"label\":\"Outro\"}}}},\"fld_3571860_1\":{\"type\":\"show\",\"group\":{\"rw_dwnpcthb\":{\"cl_twaeaii\":{\"id\":\"cl_twaeaii\",\"field\":\"fld_8297592\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_dwnpcthb\",\"label\":\"Outro\"}}}},\"fld_6470066_1\":{\"type\":\"show\",\"group\":{\"rw_vdtrsizis\":{\"cl_lqryqc\":{\"id\":\"cl_lqryqc\",\"field\":\"fld_8430632\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_vdtrsizis\",\"label\":\"Outro\"}}}},\"fld_2917925_1\":{\"type\":\"show\",\"group\":{\"rw_jmtfllzx\":{\"cl_drrkhrbul\":{\"id\":\"cl_drrkhrbul\",\"field\":\"fld_5600968\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_jmtfllzx\",\"label\":\"Outro\"}}}},\"fld_2304231_1\":{\"type\":\"show\",\"group\":{\"rw_bnmqzqq\":{\"cl_sqeed\":{\"id\":\"cl_sqeed\",\"field\":\"fld_2481233\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_bnmqzqq\",\"label\":\"Outro\"}}}},\"fld_6823998_1\":{\"type\":\"show\",\"group\":{\"rw_qdwencm\":{\"cl_oxxefeewel\":{\"id\":\"cl_oxxefeewel\",\"field\":\"fld_1996962\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qdwencm\",\"label\":\"Outro\"}}}},\"fld_2377312_1\":{\"type\":\"show\",\"group\":{\"rw_iwbduevvp\":{\"cl_ntbzwggh\":{\"id\":\"cl_ntbzwggh\",\"field\":\"fld_4596590\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_iwbduevvp\",\"label\":\"Outro\"}}}},\"fld_4147300_1\":{\"type\":\"show\",\"group\":{\"rw_wcxxmanq\":{\"cl_gqecchyabq\":{\"id\":\"cl_gqecchyabq\",\"field\":\"fld_7925824\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_wcxxmanq\",\"label\":\"Outro\"}}}},\"fld_6128378_1\":{\"type\":\"show\",\"group\":{\"rw_aizongnb\":{\"cl_wgxowlqnl\":{\"id\":\"cl_wgxowlqnl\",\"field\":\"fld_9756699\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_aizongnb\",\"label\":\"Outro\"}}}},\"fld_7039225_1\":{\"type\":\"show\",\"group\":{\"rw_llzjgsrke\":{\"cl_ictarpp\":{\"id\":\"cl_ictarpp\",\"field\":\"fld_5201432\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_llzjgsrke\",\"label\":\"Outro\"}}}},\"fld_224762_1\":{\"type\":\"show\",\"group\":{\"rw_qnjhoebz\":{\"cl_inuohkwyja\":{\"id\":\"cl_inuohkwyja\",\"field\":\"fld_1904780\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qnjhoebz\",\"label\":\"Outro\"}}}},\"fld_973027_1\":{\"type\":\"show\",\"group\":{\"rw_kmzhtcb\":{\"cl_hjyiwrbtmv\":{\"id\":\"cl_hjyiwrbtmv\",\"field\":\"fld_1633260\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kmzhtcb\",\"label\":\"Outro\"}}}},\"fld_7301016_1\":{\"type\":\"show\",\"group\":{\"rw_vbztskeqw\":{\"cl_osffexsm\":{\"id\":\"cl_osffexsm\",\"field\":\"fld_9478261\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_vbztskeqw\",\"label\":\"Outro\"}}}},\"fld_1855499_1\":{\"type\":\"show\",\"group\":{\"rw_sipaqxi\":{\"cl_pijvca\":{\"id\":\"cl_pijvca\",\"field\":\"fld_78322\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_sipaqxi\",\"label\":\"Outro\"}}}},\"fld_9690541_1\":{\"type\":\"show\",\"group\":{\"rw_kvzqryxbt\":{\"cl_onblzirm\":{\"id\":\"cl_onblzirm\",\"field\":\"fld_6108732\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kvzqryxbt\",\"label\":\"Outro\"}}}},\"fld_5947451_1\":{\"type\":\"show\",\"group\":{\"rw_asmzzneso\":{\"cl_qynoax\":{\"id\":\"cl_qynoax\",\"field\":\"fld_6841849\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_asmzzneso\",\"label\":\"Outro\"}}}},\"fld_4421454_1\":{\"type\":\"show\",\"group\":{\"rw_vzhicjq\":{\"cl_ukyqsqo\":{\"id\":\"cl_ukyqsqo\",\"field\":\"fld_2200576\",\"value\":\"Masculino\",\"compare\":\"is\",\"parent\":\"rw_vzhicjq\",\"label\":\"Masculino\"}}}},\"fld_7735289_1\":{\"type\":\"show\",\"group\":{\"rw_shcsrcvnm\":{\"cl_tqgmxo\":{\"id\":\"cl_tqgmxo\",\"field\":\"fld_4421454\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_shcsrcvnm\",\"label\":\"Outro\"}}}},\"fld_1241280_1\":{\"type\":\"show\",\"group\":{\"rw_hsmptnce\":{\"cl_myntzmpf\":{\"id\":\"cl_myntzmpf\",\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_hsmptnce\",\"label\":\"Feminino\"}}}},\"fld_437986_1\":{\"type\":\"show\",\"group\":{\"rw_bgvepfpom\":{\"cl_rovgfand\":{\"id\":\"cl_rovgfand\",\"field\":\"fld_1241280\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_bgvepfpom\",\"label\":\"Outro\"}}}},\"fld_5184946_1\":{\"type\":\"show\",\"group\":{\"rw_iunrito\":{\"cl_mgilrbfj\":{\"id\":\"cl_mgilrbfj\",\"field\":\"fld_495397\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_iunrito\",\"label\":\"Outro\"}}}},\"fld_9781446_1\":{\"type\":\"show\",\"group\":{\"rw_qglhojev\":{\"cl_jccbi\":{\"id\":\"cl_jccbi\",\"field\":\"fld_6779368\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qglhojev\",\"label\":\"Outro\"}}}},\"fld_7632005_1\":{\"type\":\"show\",\"group\":{\"rw_dceejkqxcf\":{\"cl_kcosmqubng\":{\"id\":\"cl_kcosmqubng\",\"field\":\"fld_8989705\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_dceejkqxcf\",\"label\":\"Outro\"}}}},\"fld_411163_1\":{\"type\":\"show\",\"group\":{\"rw_kulqlzn\":{\"cl_yxmmokdlo\":{\"id\":\"cl_yxmmokdlo\",\"field\":\"fld_9768910\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kulqlzn\",\"label\":\"Outro\"}}}},\"fld_846866_1\":{\"type\":\"show\",\"group\":{\"rw_arrgye\":{\"cl_qxxjxyyp\":{\"id\":\"cl_qxxjxyyp\",\"field\":\"fld_3099297\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_arrgye\",\"label\":\"Outro\"}}}},\"fld_5703829_1\":{\"type\":\"show\",\"group\":{\"rw_qfgsil\":{\"cl_ioopjmjnz\":{\"id\":\"cl_ioopjmjnz\",\"field\":\"fld_5604272\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qfgsil\",\"label\":\"Outro\"}}}},\"fld_1642058_1\":{\"type\":\"show\",\"group\":{\"rw_werexpmda\":{\"cl_yxfpsu\":{\"id\":\"cl_yxfpsu\",\"field\":\"fld_6042275\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_werexpmda\",\"label\":\"Outro\"}}}},\"fld_2102016_1\":{\"type\":\"show\",\"group\":{\"rw_saqhee\":{\"cl_fmzpdib\":{\"id\":\"cl_fmzpdib\",\"field\":\"fld_8328657\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_saqhee\",\"label\":\"Outro\"}}}},\"fld_7252825_1\":{\"type\":\"show\",\"group\":{\"rw_aieriudw\":{\"cl_kdftnkg\":{\"id\":\"cl_kdftnkg\",\"field\":\"fld_8454960\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_aieriudw\",\"label\":\"Outro\"}}}}};\r\n<\/script>\r\n<script type=\"text\/html\" id=\"conditional-fld_9442215_1-tmpl\">\r\n<div data-field-wrapper=\"fld_9442215\" class=\"form-group\" id=\"fld_9442215_1-wrap\">\r\n\t<label id=\"fld_9442215Label\" for=\"fld_9442215_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9442215\" class=\" form-control\" id=\"fld_9442215_1\" name=\"fld_9442215\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9442215Label\" aria-describedby=\"fld_9442215Caption\" >\t\t<span id=\"fld_9442215Caption\" class=\"help-block\">Informe qual estado civil<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7633772_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7633772\" class=\"form-group\" id=\"fld_7633772_1-wrap\">\r\n\t<label id=\"fld_7633772Label\" for=\"fld_7633772_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7633772\" class=\" form-control\" id=\"fld_7633772_1\" name=\"fld_7633772\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7633772Label\" aria-describedby=\"fld_7633772Caption\" >\t\t<span id=\"fld_7633772Caption\" class=\"help-block\">Informe qual escolaridade<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_783295_1-tmpl\">\r\n<div data-field-wrapper=\"fld_783295\" class=\"form-group\" id=\"fld_783295_1-wrap\">\r\n<label id=\"fld_783295Label\" for=\"fld_783295_1\" class=\"control-label\">Gestante <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_783295_1_opt1721878\"><input type=\"radio\" id=\"fld_783295_1_opt1721878\" data-field=\"fld_783295\" class=\"fld_783295_1 option-required\" name=\"fld_783295\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_783295_1\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o\" for=\"fld_783295_1_opt1874201\"><input type=\"radio\" id=\"fld_783295_1_opt1874201\" data-field=\"fld_783295\" class=\"fld_783295_1 option-required\" name=\"fld_783295\" value=\"N\u00e3o\"   required=\"required\" data-radio-field=\"fld_783295_1\" data-type=\"radio\" data-calc-value=\"N\u00e3o\" \/>\n\t\t\tN\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1576420_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1576420\" class=\"form-group\" id=\"fld_1576420_1-wrap\">\r\n\t<label id=\"fld_1576420Label\" for=\"fld_1576420_1\" class=\"control-label\">Quantos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"number\" data-field=\"fld_1576420\" class=\" form-control\" id=\"fld_1576420_1\" name=\"fld_1576420\" value=\"\" data-type=\"number\" data-parsley-type=\"number\" aria-required=\"true\"   aria-labelledby=\"fld_1576420Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9024547_1-tmpl\">\r\n<div data-field-wrapper=\"fld_9024547\" class=\"form-group\" id=\"fld_9024547_1-wrap\">\r\n\t<label id=\"fld_9024547Label\" for=\"fld_9024547_1\" class=\"control-label\">Descreva a gesta\u00e7\u00e3o(\u00f5es) e parto(s) <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9024547\" value=\"\" data-field=\"fld_9024547\" class=\"form-control\" id=\"fld_9024547_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9024547Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3885880_1-tmpl\">\r\n<div data-field-wrapper=\"fld_3885880\" class=\"form-group\" id=\"fld_3885880_1-wrap\">\r\n\t<label id=\"fld_3885880Label\" for=\"fld_3885880_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_3885880\" class=\" form-control\" id=\"fld_3885880_1\" name=\"fld_3885880\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_3885880Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6650295_1-tmpl\">\r\n<div data-field-wrapper=\"fld_6650295\" class=\"form-group\" id=\"fld_6650295_1-wrap\">\r\n\t<label id=\"fld_6650295Label\" for=\"fld_6650295_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6650295\" class=\" form-control\" id=\"fld_6650295_1\" name=\"fld_6650295\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6650295Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1530349_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1530349\" class=\"form-group\" id=\"fld_1530349_1-wrap\">\r\n\t<label id=\"fld_1530349Label\" for=\"fld_1530349_1\" class=\"control-label\">Complementar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1530349\" class=\" form-control\" id=\"fld_1530349_1\" name=\"fld_1530349\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1530349Label\" aria-describedby=\"fld_1530349Caption\" >\t\t<span id=\"fld_1530349Caption\" class=\"help-block\">Ex : Se possui obtura\u00e7\u00f5es, quantas? Se possui pr\u00f3tese ou membros artificiais, qual?<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3043002_1-tmpl\">\r\n<div data-field-wrapper=\"fld_3043002\" class=\"form-group\" id=\"fld_3043002_1-wrap\">\r\n\t<label id=\"fld_3043002Label\" for=\"fld_3043002_1\" class=\"control-label\">Descreva o(s) hist\u00f3rico(s) m\u00e9dico(s) marcado(s) acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3043002\" value=\"\" data-field=\"fld_3043002\" class=\"form-control\" id=\"fld_3043002_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3043002Label\" aria-describedby=\"fld_3043002Caption\" ><\/textarea>\n\t\t<span id=\"fld_3043002Caption\" class=\"help-block\">Motivo, m\u00eas e ano, tempo de interna\u00e7\u00e3o, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1619118_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1619118\" class=\"form-group\" id=\"fld_1619118_1-wrap\">\r\n\t<label id=\"fld_1619118Label\" for=\"fld_1619118_1\" class=\"control-label\">Fale sobre as alergias marcadas acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1619118\" value=\"\" data-field=\"fld_1619118\" class=\"form-control\" id=\"fld_1619118_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1619118Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7494269_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7494269\" class=\"form-group\" id=\"fld_7494269_1-wrap\">\r\n\t<label id=\"fld_7494269Label\" for=\"fld_7494269_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7494269\" class=\" form-control\" id=\"fld_7494269_1\" name=\"fld_7494269\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7494269Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6094755_1-tmpl\">\r\n<div data-field-wrapper=\"fld_6094755\" class=\"form-group\" id=\"fld_6094755_1-wrap\">\r\n\t<label id=\"fld_6094755Label\" for=\"fld_6094755_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6094755\" class=\" form-control\" id=\"fld_6094755_1\" name=\"fld_6094755\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6094755Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2575749_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2575749\" class=\"form-group\" id=\"fld_2575749_1-wrap\">\r\n\t<label id=\"fld_2575749Label\" for=\"fld_2575749_1\" class=\"control-label\">Quais? Tem inten\u00e7\u00e3o de parar o uso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2575749\" value=\"\" data-field=\"fld_2575749\" class=\"form-control\" id=\"fld_2575749_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2575749Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7520435_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7520435\" class=\"form-group\" id=\"fld_7520435_1-wrap\">\r\n\t<label id=\"fld_7520435Label\" for=\"fld_7520435_1\" class=\"control-label\">Quantos vezes ao dia fuma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7520435\" value=\"\" data-field=\"fld_7520435\" class=\"form-control\" id=\"fld_7520435_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7520435Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_977328_1-tmpl\">\r\n<div data-field-wrapper=\"fld_977328\" class=\"form-group\" id=\"fld_977328_1-wrap\">\r\n\t<label id=\"fld_977328Label\" for=\"fld_977328_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_977328\" class=\" form-control\" id=\"fld_977328_1\" name=\"fld_977328\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_977328Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2985878_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2985878\" class=\"form-group\" id=\"fld_2985878_1-wrap\">\r\n\t<label id=\"fld_2985878Label\" for=\"fld_2985878_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2985878\" class=\" form-control\" id=\"fld_2985878_1\" name=\"fld_2985878\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2985878Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_950222_1-tmpl\">\r\n<div data-field-wrapper=\"fld_950222\" class=\"form-group\" id=\"fld_950222_1-wrap\">\r\n\t<label id=\"fld_950222Label\" for=\"fld_950222_1\" class=\"control-label\">Descreva? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_950222\" value=\"\" data-field=\"fld_950222\" class=\"form-control\" id=\"fld_950222_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_950222Label\" aria-describedby=\"fld_950222Caption\" ><\/textarea>\n\t\t<span id=\"fld_950222Caption\" class=\"help-block\">Qual bebida e quantas doses ou a quanto tempo parou<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_8312371_1-tmpl\">\r\n<div data-field-wrapper=\"fld_8312371\" class=\"form-group\" id=\"fld_8312371_1-wrap\">\r\n\t<label id=\"fld_8312371Label\" for=\"fld_8312371_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_8312371\" class=\" form-control\" id=\"fld_8312371_1\" name=\"fld_8312371\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_8312371Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_804883_1-tmpl\">\r\n<div data-field-wrapper=\"fld_804883\" class=\"form-group\" id=\"fld_804883_1-wrap\">\r\n\t<label id=\"fld_804883Label\" for=\"fld_804883_1\" class=\"control-label\">Descreva <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_804883\" value=\"\" data-field=\"fld_804883\" class=\"form-control\" id=\"fld_804883_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_804883Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_821839_1-tmpl\">\r\n<div data-field-wrapper=\"fld_821839\" class=\"form-group\" id=\"fld_821839_1-wrap\">\r\n\t<label id=\"fld_821839Label\" for=\"fld_821839_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_821839\" class=\" form-control\" id=\"fld_821839_1\" name=\"fld_821839\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_821839Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3571860_1-tmpl\">\r\n<div data-field-wrapper=\"fld_3571860\" class=\"form-group\" id=\"fld_3571860_1-wrap\">\r\n\t<label id=\"fld_3571860Label\" for=\"fld_3571860_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_3571860\" class=\" form-control\" id=\"fld_3571860_1\" name=\"fld_3571860\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_3571860Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6470066_1-tmpl\">\r\n<div data-field-wrapper=\"fld_6470066\" class=\"form-group\" id=\"fld_6470066_1-wrap\">\r\n\t<label id=\"fld_6470066Label\" for=\"fld_6470066_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6470066\" class=\" form-control\" id=\"fld_6470066_1\" name=\"fld_6470066\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6470066Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2917925_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2917925\" class=\"form-group\" id=\"fld_2917925_1-wrap\">\r\n\t<label id=\"fld_2917925Label\" for=\"fld_2917925_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2917925\" class=\" form-control\" id=\"fld_2917925_1\" name=\"fld_2917925\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2917925Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2304231_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2304231\" class=\"form-group\" id=\"fld_2304231_1-wrap\">\r\n\t<label id=\"fld_2304231Label\" for=\"fld_2304231_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2304231\" class=\" form-control\" id=\"fld_2304231_1\" name=\"fld_2304231\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2304231Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6823998_1-tmpl\">\r\n<div data-field-wrapper=\"fld_6823998\" class=\"form-group\" id=\"fld_6823998_1-wrap\">\r\n\t<label id=\"fld_6823998Label\" for=\"fld_6823998_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6823998\" class=\" form-control\" id=\"fld_6823998_1\" name=\"fld_6823998\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6823998Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2377312_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2377312\" class=\"form-group\" id=\"fld_2377312_1-wrap\">\r\n\t<label id=\"fld_2377312Label\" for=\"fld_2377312_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2377312\" class=\" form-control\" id=\"fld_2377312_1\" name=\"fld_2377312\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2377312Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_4147300_1-tmpl\">\r\n<div data-field-wrapper=\"fld_4147300\" class=\"form-group\" id=\"fld_4147300_1-wrap\">\r\n\t<label id=\"fld_4147300Label\" for=\"fld_4147300_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_4147300\" class=\" form-control\" id=\"fld_4147300_1\" name=\"fld_4147300\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4147300Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6128378_1-tmpl\">\r\n<div data-field-wrapper=\"fld_6128378\" class=\"form-group\" id=\"fld_6128378_1-wrap\">\r\n\t<label id=\"fld_6128378Label\" for=\"fld_6128378_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6128378\" class=\" form-control\" id=\"fld_6128378_1\" name=\"fld_6128378\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6128378Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7039225_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7039225\" class=\"form-group\" id=\"fld_7039225_1-wrap\">\r\n\t<label id=\"fld_7039225Label\" for=\"fld_7039225_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7039225\" class=\" form-control\" id=\"fld_7039225_1\" name=\"fld_7039225\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7039225Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_224762_1-tmpl\">\r\n<div data-field-wrapper=\"fld_224762\" class=\"form-group\" id=\"fld_224762_1-wrap\">\r\n\t<label id=\"fld_224762Label\" for=\"fld_224762_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_224762\" class=\" form-control\" id=\"fld_224762_1\" name=\"fld_224762\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_224762Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_973027_1-tmpl\">\r\n<div data-field-wrapper=\"fld_973027\" class=\"form-group\" id=\"fld_973027_1-wrap\">\r\n\t<label id=\"fld_973027Label\" for=\"fld_973027_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_973027\" class=\" form-control\" id=\"fld_973027_1\" name=\"fld_973027\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_973027Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7301016_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7301016\" class=\"form-group\" id=\"fld_7301016_1-wrap\">\r\n\t<label id=\"fld_7301016Label\" for=\"fld_7301016_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7301016\" class=\" form-control\" id=\"fld_7301016_1\" name=\"fld_7301016\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7301016Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1855499_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1855499\" class=\"form-group\" id=\"fld_1855499_1-wrap\">\r\n\t<label id=\"fld_1855499Label\" for=\"fld_1855499_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1855499\" class=\" form-control\" id=\"fld_1855499_1\" name=\"fld_1855499\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1855499Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9690541_1-tmpl\">\r\n<div data-field-wrapper=\"fld_9690541\" class=\"form-group\" id=\"fld_9690541_1-wrap\">\r\n\t<label id=\"fld_9690541Label\" for=\"fld_9690541_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9690541\" class=\" form-control\" id=\"fld_9690541_1\" name=\"fld_9690541\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9690541Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5947451_1-tmpl\">\r\n<div data-field-wrapper=\"fld_5947451\" class=\"form-group\" id=\"fld_5947451_1-wrap\">\r\n\t<label id=\"fld_5947451Label\" for=\"fld_5947451_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5947451\" class=\" form-control\" id=\"fld_5947451_1\" name=\"fld_5947451\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5947451Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_4421454_1-tmpl\">\r\n<div data-field-wrapper=\"fld_4421454\" class=\"form-group\" id=\"fld_4421454_1-wrap\">\r\n\t<label id=\"fld_4421454Label\" for=\"fld_4421454_1\" class=\"control-label\">Problemas exclusivos para sexo Masculino <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1563715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1563715\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1563715]\"\n                                value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                            >\n                    Dor durante rela\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1979733\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor durante ere\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1979733\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1979733]\"\n                                value=\"Dor durante ere\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor durante ere\u00e7\u00e3o\"\n                            >\n                    Dor durante ere\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1366036\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor durante ejacula\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1366036\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1366036]\"\n                                value=\"Dor durante ejacula\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor durante ejacula\u00e7\u00e3o\"\n                            >\n                    Dor durante ejacula\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1086262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor durante mic\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1086262\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1086262]\"\n                                value=\"Dor durante mic\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor durante mic\u00e7\u00e3o\"\n                            >\n                    Dor durante mic\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1186040\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor na pr\u00f3stata\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1186040\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1186040]\"\n                                value=\"Dor na pr\u00f3stata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor na pr\u00f3stata\"\n                            >\n                    Dor na pr\u00f3stata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1741447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1741447\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1741447]\"\n                                value=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                            >\n                    Dor ou incha\u00e7o nos test\u00edculos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1436317\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Emiss\u00f5es noturnas\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1436317\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1436317]\"\n                                value=\"Emiss\u00f5es noturnas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Emiss\u00f5es noturnas\"\n                            >\n                    Emiss\u00f5es noturnas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1760455\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Ejacula\u00e7\u00e3o precoce\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1760455\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1760455]\"\n                                value=\"Ejacula\u00e7\u00e3o precoce\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Ejacula\u00e7\u00e3o precoce\"\n                            >\n                    Ejacula\u00e7\u00e3o precoce                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt2007966\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de ere\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt2007966\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt2007966]\"\n                                value=\"Dificuldade de ere\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Dificuldade de ere\u00e7\u00e3o\"\n                            >\n                    Dificuldade de ere\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1646396\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Impot\u00eancia sexual\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1646396\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1646396]\"\n                                value=\"Impot\u00eancia sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Impot\u00eancia sexual\"\n                            >\n                    Impot\u00eancia sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt2070743\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Infertilidade\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt2070743\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt2070743]\"\n                                value=\"Infertilidade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Infertilidade\"\n                            >\n                    Infertilidade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt1276981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt1276981\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt1276981]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_1_opt2051047\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_1\" data-parsley-multiple=\"fld_4421454_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_1_opt2051047\"\n                                class=\"fld_4421454_1 option-required\"\n                                name=\"fld_4421454[opt2051047]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7735289_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7735289\" class=\"form-group\" id=\"fld_7735289_1-wrap\">\r\n\t<label id=\"fld_7735289Label\" for=\"fld_7735289_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7735289\" class=\" form-control\" id=\"fld_7735289_1\" name=\"fld_7735289\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7735289Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1241280_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1241280\" class=\"form-group\" id=\"fld_1241280_1-wrap\">\r\n\t<label id=\"fld_1241280Label\" for=\"fld_1241280_1\" class=\"control-label\">Problemas exclusivos para sexo Feminino <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1200983\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1200983\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1200983]\"\n                                value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                            >\n                    Dor durante rela\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1333721\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Problemas com orgasmo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1333721\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1333721]\"\n                                value=\"Problemas com orgasmo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Problemas com orgasmo\"\n                            >\n                    Problemas com orgasmo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1718785\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Secura vaginal\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1718785\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1718785]\"\n                                value=\"Secura vaginal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Secura vaginal\"\n                            >\n                    Secura vaginal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1057766\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Gravidez\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1057766\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1057766]\"\n                                value=\"Gravidez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Gravidez\"\n                            >\n                    Gravidez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1085322\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Aborto\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1085322\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1085322]\"\n                                value=\"Aborto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Aborto\"\n                            >\n                    Aborto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1641879\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Aborto espont\u00e2neo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1641879\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1641879]\"\n                                value=\"Aborto espont\u00e2neo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Aborto espont\u00e2neo\"\n                            >\n                    Aborto espont\u00e2neo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1094483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Infertilidade\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1094483\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1094483]\"\n                                value=\"Infertilidade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Infertilidade\"\n                            >\n                    Infertilidade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1612625\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"N\u00f3dulos nas mamas\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1612625\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1612625]\"\n                                value=\"N\u00f3dulos nas mamas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"N\u00f3dulos nas mamas\"\n                            >\n                    N\u00f3dulos nas mamas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1319807\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menopausa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1319807\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1319807]\"\n                                value=\"Menopausa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menopausa\"\n                            >\n                    Menopausa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1081886\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Normal\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1081886\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1081886]\"\n                                value=\"Menstrua\u00e7\u00e3o - Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Normal\"\n                            >\n                    Menstrua\u00e7\u00e3o - Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1412242\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Cedo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1412242\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1412242]\"\n                                value=\"Menstrua\u00e7\u00e3o - Cedo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Cedo\"\n                            >\n                    Menstrua\u00e7\u00e3o - Cedo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt2030432\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Tardia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt2030432\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt2030432]\"\n                                value=\"Menstrua\u00e7\u00e3o - Tardia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Tardia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Tardia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1077120\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Irregular\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1077120\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1077120]\"\n                                value=\"Menstrua\u00e7\u00e3o - Irregular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Irregular\"\n                            >\n                    Menstrua\u00e7\u00e3o - Irregular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1315473\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1315473\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1315473]\"\n                                value=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                            >\n                    Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt2030002\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt2030002\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt2030002]\"\n                                value=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                            >\n                    Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1317140\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Pesada\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1317140\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1317140]\"\n                                value=\"Menstrua\u00e7\u00e3o - Pesada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Pesada\"\n                            >\n                    Menstrua\u00e7\u00e3o - Pesada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1618328\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Escassa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1618328\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1618328]\"\n                                value=\"Menstrua\u00e7\u00e3o - Escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Escassa\"\n                            >\n                    Menstrua\u00e7\u00e3o - Escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1326251\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1326251\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1326251]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dolorosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1501510\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1501510\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1501510]\"\n                                value=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Metrorragia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1784189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1784189\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1784189]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dismenorreia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt2095099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt2095099\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt2095099]\"\n                                value=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                            >\n                    Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1329220\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1329220\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1329220]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_1_opt1970402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_1\" data-parsley-multiple=\"fld_1241280_1\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_1_opt1970402\"\n                                class=\"fld_1241280_1 option-required\"\n                                name=\"fld_1241280[opt1970402]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_1\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_437986_1-tmpl\">\r\n<div data-field-wrapper=\"fld_437986\" class=\"form-group\" id=\"fld_437986_1-wrap\">\r\n\t<label id=\"fld_437986Label\" for=\"fld_437986_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_437986\" class=\" form-control\" id=\"fld_437986_1\" name=\"fld_437986\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_437986Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5184946_1-tmpl\">\r\n<div data-field-wrapper=\"fld_5184946\" class=\"form-group\" id=\"fld_5184946_1-wrap\">\r\n\t<label id=\"fld_5184946Label\" for=\"fld_5184946_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5184946\" class=\" form-control\" id=\"fld_5184946_1\" name=\"fld_5184946\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5184946Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9781446_1-tmpl\">\r\n<div data-field-wrapper=\"fld_9781446\" class=\"form-group\" id=\"fld_9781446_1-wrap\">\r\n\t<label id=\"fld_9781446Label\" for=\"fld_9781446_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9781446\" class=\" form-control\" id=\"fld_9781446_1\" name=\"fld_9781446\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9781446Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7632005_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7632005\" class=\"form-group\" id=\"fld_7632005_1-wrap\">\r\n\t<label id=\"fld_7632005Label\" for=\"fld_7632005_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7632005\" class=\" form-control\" id=\"fld_7632005_1\" name=\"fld_7632005\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7632005Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_411163_1-tmpl\">\r\n<div data-field-wrapper=\"fld_411163\" class=\"form-group\" id=\"fld_411163_1-wrap\">\r\n\t<label id=\"fld_411163Label\" for=\"fld_411163_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_411163\" class=\" form-control\" id=\"fld_411163_1\" name=\"fld_411163\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_411163Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_846866_1-tmpl\">\r\n<div data-field-wrapper=\"fld_846866\" class=\"form-group\" id=\"fld_846866_1-wrap\">\r\n\t<label id=\"fld_846866Label\" for=\"fld_846866_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_846866\" class=\" form-control\" id=\"fld_846866_1\" name=\"fld_846866\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_846866Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5703829_1-tmpl\">\r\n<div data-field-wrapper=\"fld_5703829\" class=\"form-group\" id=\"fld_5703829_1-wrap\">\r\n\t<label id=\"fld_5703829Label\" for=\"fld_5703829_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5703829\" class=\" form-control\" id=\"fld_5703829_1\" name=\"fld_5703829\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5703829Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1642058_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1642058\" class=\"form-group\" id=\"fld_1642058_1-wrap\">\r\n\t<label id=\"fld_1642058Label\" for=\"fld_1642058_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1642058\" class=\" form-control\" id=\"fld_1642058_1\" name=\"fld_1642058\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1642058Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2102016_1-tmpl\">\r\n<div data-field-wrapper=\"fld_2102016\" class=\"form-group\" id=\"fld_2102016_1-wrap\">\r\n\t<label id=\"fld_2102016Label\" for=\"fld_2102016_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2102016\" class=\" form-control\" id=\"fld_2102016_1\" name=\"fld_2102016\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2102016Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7252825_1-tmpl\">\r\n<div data-field-wrapper=\"fld_7252825\" class=\"form-group\" id=\"fld_7252825_1-wrap\">\r\n\t<label id=\"fld_7252825Label\" for=\"fld_7252825_1\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7252825\" value=\"\" data-field=\"fld_7252825\" class=\"form-control\" id=\"fld_7252825_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7252825Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n[\/et_pb_text][et_pb_divider color=&#8221;#7cc68d&#8221; divider_weight=&#8221;2px&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; width=&#8221;150px&#8221; custom_margin=&#8221;15px||||false|false&#8221; module_alignment_tablet=&#8221;&#8221; module_alignment_phone=&#8221;center&#8221; module_alignment_last_edited=&#8221;on|phone&#8221;][\/et_pb_divider][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; specialty=&#8221;on&#8221; admin_label=&#8221;Afilia\u00e7\u00f5es&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#fffbf5&#8243; width=&#8221;100%&#8221; max_width=&#8221;100%&#8221; module_alignment=&#8221;center&#8221; inner_max_width=&#8221;70%&#8221; custom_margin=&#8221;0px||40px||false|false&#8221; custom_padding=&#8221;0px||||false|false&#8221; global_module=&#8221;554&#8243; saved_tabs=&#8221;all&#8221; collapsed=&#8221;on&#8221;][et_pb_column type=&#8221;3_4&#8243; specialty_columns=&#8221;3&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_row_inner admin_label=&#8221;T\u00edtulo &#8211; Terapeuticas&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;||0px||false|false&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_text admin_label=&#8221;Terapeuta Credenciado&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; header_3_text_align=&#8221;center&#8221;]<\/p>\n<h3>Terapeuta Credenciado<\/h3>\n<p>[\/et_pb_text][et_pb_divider color=&#8221;#7cc68d&#8221; divider_weight=&#8221;2px&#8221; _builder_version=&#8221;4.5.7&#8243; width=&#8221;100px&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;10px||0px||false|false&#8221; locked=&#8221;off&#8221;][\/et_pb_divider][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner column_structure=&#8221;1_3,1_3,1_3&#8243; admin_label=&#8221;Lista &#8211; afilia\u00e7\u00f5es&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;0px||35px||false|false&#8221; custom_padding=&#8221;||||false|false&#8221; collapsed=&#8221;off&#8221;][et_pb_column_inner type=&#8221;1_3&#8243; saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_image src=&#8221;https:\/\/www.newstar.com.br\/wp-content\/uploads\/abrath.jpg&#8221; alt=&#8221;Abrath&#8221; title_text=&#8221;Abrath&#8221; url=&#8221;https:\/\/www.abrath.org.br\/&#8221; url_new_window=&#8221;on&#8221; show_bottom_space=&#8221;off&#8221; align=&#8221;center&#8221; admin_label=&#8221;Abrath &#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||15px||false|false&#8221;][\/et_pb_image][\/et_pb_column_inner][et_pb_column_inner type=&#8221;1_3&#8243; saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_image src=&#8221;https:\/\/www.newstar.com.br\/wp-content\/uploads\/conahom.jpg&#8221; alt=&#8221;Conahom&#8221; title_text=&#8221;Conahom&#8221; url=&#8221;https:\/\/conahom.com\/&#8221; url_new_window=&#8221;on&#8221; show_bottom_space=&#8221;off&#8221; align=&#8221;center&#8221; admin_label=&#8221;Conahom&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;||15px||false|false&#8221;][\/et_pb_image][et_pb_image src=&#8221;https:\/\/www.newstar.com.br\/wp-content\/uploads\/itr.jpg&#8221; alt=&#8221;ITR&#8221; title_text=&#8221;ITR&#8221; url=&#8221;https:\/\/brasil.itr.life\/&#8221; url_new_window=&#8221;on&#8221; align=&#8221;center&#8221; admin_label=&#8221;ITR&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][\/et_pb_image][\/et_pb_column_inner][et_pb_column_inner type=&#8221;1_3&#8243; saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_image src=&#8221;https:\/\/www.newstar.com.br\/wp-content\/uploads\/sltm.jpg&#8221; alt=&#8221;ITR&#8221; title_text=&#8221;sltm&#8221; url=&#8221;https:\/\/sociedadelivre.org\/&#8221; url_new_window=&#8221;on&#8221; align=&#8221;center&#8221; admin_label=&#8221;SLTM&#8221; _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; locked=&#8221;off&#8221;][\/et_pb_image][\/et_pb_column_inner][\/et_pb_row_inner][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;T\u00edtulo Publicit\u00e1ria&#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; header_3_text_align=&#8221;center&#8221; custom_margin=&#8221;||10px||false|false&#8221; custom_padding=&#8221;||0px||false|false&#8221;]<\/p>\n<h3>Filiado \u00e0<\/h3>\n<p>[\/et_pb_text][et_pb_divider color=&#8221;#7cc68d&#8221; divider_weight=&#8221;2px&#8221; _builder_version=&#8221;4.5.7&#8243; width=&#8221;100px&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;0px||0px||false|false&#8221; locked=&#8221;off&#8221;][\/et_pb_divider][et_pb_image src=&#8221;https:\/\/www.newstar.com.br\/wp-content\/uploads\/brasil-terapias.jpg&#8221; alt=&#8221;Brasil Terapias &#8221; title_text=&#8221;Brasil Terapias &#8221; url=&#8221;https:\/\/www.brasilterapias.com.br\/&#8221; url_new_window=&#8221;on&#8221; align=&#8221;center&#8221; admin_label=&#8221;Brasil Terapias &#8221; _builder_version=&#8221;4.5.7&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;33px||||false|false&#8221;][\/et_pb_image][\/et_pb_column][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Formul\u00e1rio Anamnese Aromaterapia Florais de Bach Fitoterapia Homeopatia<div class=\"caldera-grid\" id=\"caldera_form_2\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF603020f491e20\"><div id=\"caldera_notices_2\" data-spinner=\"https:\/\/www.newstar.com.br\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"2\" class=\"CF603020f491e20 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF603020f491e20_2\" data-form-id=\"CF603020f491e20\" aria-label=\"Anamnese de Naturopatia\" data-target=\"#caldera_notices_2\" data-template=\"#cfajax_CF603020f491e20-tmpl\" data-cfajax=\"CF603020f491e20\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/www.newstar.com.br\/cf-api\/CF603020f491e20\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF603020f491e20\" name=\"_cf_verify\" value=\"59e59003b1\"  data-nonce-time=\"1790147244\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2747\" \/><div id=\"cf2-CF603020f491e20_2\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF603020f491e20\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"2\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF603020f491e20\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"2747\">\r\n<span class=\"caldera-grid\"><ol class=\"breadcrumb\" data-form=\"caldera_form_2\" id=\"caldera-forms-breadcrumb_2\">\r\n<li class=\"active\"><a aria-controls=\"form_page_2_pg_1\" aria-expanded=\"true\" id=\"breadcrumb_2_pg_1\" href=\"?cf_pg=1\" data-page=\"1\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Dados Pessoais\">Dados Pessoais<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_2\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_2\" href=\"?cf_pg=2\" data-page=\"2\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Dados Complementares\">Dados Complementares<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_3\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_3\" href=\"?cf_pg=3\" data-page=\"3\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Dados Terapia\">Dados Terapia<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_4\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_4\" href=\"?cf_pg=4\" data-page=\"4\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Estilo de Vida\">Estilo de Vida<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_5\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_5\" href=\"?cf_pg=5\" data-page=\"5\" data-pagenav=\"caldera_form_2\" title=\"Navigate to H\u00e1bitos Alimentares\">H\u00e1bitos Alimentares<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_6\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_6\" href=\"?cf_pg=6\" data-page=\"6\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Sa\u00fade Familiar 1\">Sa\u00fade Familiar 1<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_7\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_7\" href=\"?cf_pg=7\" data-page=\"7\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Sa\u00fade Familiar 2\">Sa\u00fade Familiar 2<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_8\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_8\" href=\"?cf_pg=8\" data-page=\"8\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Sintomas F\u00edsicos 1\">Sintomas F\u00edsicos 1<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_9\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_9\" href=\"?cf_pg=9\" data-page=\"9\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Sintomas F\u00edsicos 2\">Sintomas F\u00edsicos 2<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_10\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_10\" href=\"?cf_pg=10\" data-page=\"10\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Vis\u00e3o Pessoal\">Vis\u00e3o Pessoal<\/a><\/li>\r\n<li><a aria-controls=\"form_page_2_pg_11\" aria-expanded=\"false\" id=\"breadcrumb_2_pg_11\" href=\"?cf_pg=11\" data-page=\"11\" data-pagenav=\"caldera_form_2\" title=\"Navigate to Perfil Psicol\u00f3gico\">Perfil Psicol\u00f3gico<\/a><\/li>\r\n<\/ol><\/span>\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Url<\/label><input type=\"text\" name=\"url\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"form_page_2_pg_1\" data-formpage=\"1\" class=\"caldera-form-page\" style=\"display:block;\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_1\" aria-hidden=\"false\"><div id=\"CF603020f491e20_2-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9348355\" class=\"form-group\" id=\"fld_9348355_2-wrap\">\r\n\t<label id=\"fld_9348355Label\" for=\"fld_9348355_2\" class=\"control-label\">E-mail <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_9348355\" class=\" form-control\" id=\"fld_9348355_2\" name=\"fld_9348355\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_9348355Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7732289\" class=\"form-group\" id=\"fld_7732289_2-wrap\">\r\n\t<label id=\"fld_7732289Label\" for=\"fld_7732289_2\" class=\"control-label\">Nome Completo <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7732289\" class=\" form-control\" id=\"fld_7732289_2\" name=\"fld_7732289\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7732289Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-2\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5587279\" class=\"form-group\" id=\"fld_5587279_2-wrap\">\r\n\t<label id=\"fld_5587279Label\" for=\"fld_5587279_2\" class=\"control-label\">N\u00famero Identidade <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '[9{*}]'\"  required type=\"text\" data-field=\"fld_5587279\" class=\" form-control\" id=\"fld_5587279_2\" name=\"fld_5587279\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5587279Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_4455205\" class=\"form-group\" id=\"fld_4455205_2-wrap\">\r\n\t<label id=\"fld_4455205Label\" for=\"fld_4455205_2\" class=\"control-label\">CPF <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '999.999.999\/99'\"  required type=\"text\" data-field=\"fld_4455205\" class=\" form-control\" id=\"fld_4455205_2\" name=\"fld_4455205\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4455205Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3535274\" class=\"form-group\" id=\"fld_3535274_2-wrap\">\r\n\t<label id=\"fld_3535274Label\" for=\"fld_3535274_2\" class=\"control-label\">Telefone <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"tel\" data-field=\"fld_3535274\" class=\" form-control\" id=\"fld_3535274_2\" name=\"fld_3535274\" value=\"\" data-type=\"phone_better\" aria-required=\"true\"   aria-labelledby=\"fld_3535274Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1165696\" class=\"form-group\" id=\"fld_1165696_2-wrap\">\r\n\t<label id=\"fld_1165696Label\" for=\"fld_1165696_2\" class=\"control-label\">Telefone Emerg\u00eancia <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"tel\" data-field=\"fld_1165696\" class=\" form-control\" id=\"fld_1165696_2\" name=\"fld_1165696\" value=\"\" data-type=\"phone_better\" aria-required=\"true\"   aria-labelledby=\"fld_1165696Label\" aria-describedby=\"fld_1165696Caption\" >\t\t<span id=\"fld_1165696Caption\" class=\"help-block\">(De pessoa pr\u00f3xima para caso de doen\u00e7a ou problema card\u00edaco,  convuls\u00e3o, epilepsia, depress\u00e3o ou taquicardia)<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \">\n<div data-field-wrapper=\"fld_1898311\" class=\"form-group\" id=\"fld_1898311_2-wrap\">\r\n\t<label id=\"fld_1898311Label\" for=\"fld_1898311_2\" class=\"control-label\">Data de Nascimento <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  type=\"text\" data-provide=\"cfdatepicker\" name=\"fld_1898311\" value=\"\" id=\"fld_1898311_2\" data-field=\"fld_1898311\" class=\"form-control cfdatepicker is-cfdatepicker\" data-date-format=\"dd-mm-yyyy\" required=\"1\" data-date-start-view=\"month\"  data-date-start-date=\"-100y\" data-date-end-date=\"0d\" data-date-language=\"pt-BR\"   aria-labelledby=\"fld_1898311Label\" required  \/>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2200576\" class=\"form-group\" id=\"fld_2200576_2-wrap\">\r\n<label id=\"fld_2200576Label\" for=\"fld_2200576_2\" class=\"control-label\">Sexo Biol\u00f3gico <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Masculino\" for=\"fld_2200576_2_opt1079885\"><input type=\"radio\" id=\"fld_2200576_2_opt1079885\" data-field=\"fld_2200576\" class=\"fld_2200576_2 option-required\" name=\"fld_2200576\" value=\"Masculino\"   required=\"required\" data-radio-field=\"fld_2200576_2\" data-type=\"radio\" data-calc-value=\"Masculino\" \/>\n\t\t\tMasculino\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Feminino\" for=\"fld_2200576_2_opt1850032\"><input type=\"radio\" id=\"fld_2200576_2_opt1850032\" data-field=\"fld_2200576\" class=\"fld_2200576_2 option-required\" name=\"fld_2200576\" value=\"Feminino\"   required=\"required\" data-radio-field=\"fld_2200576_2\" data-type=\"radio\" data-calc-value=\"Feminino\" \/>\n\t\t\tFeminino\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1574495\" class=\"form-group\" id=\"fld_1574495_2-wrap\">\r\n<label id=\"fld_1574495Label\" for=\"fld_1574495_2\" class=\"control-label\">Estado Civil <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Solteiro(a)\" for=\"fld_1574495_2_opt1616306\"><input type=\"radio\" id=\"fld_1574495_2_opt1616306\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Solteiro(a)\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Solteiro(a)\" \/>\n\t\t\tSolteiro(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Casado(a)\" for=\"fld_1574495_2_opt1371399\"><input type=\"radio\" id=\"fld_1574495_2_opt1371399\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Casado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Casado(a)\" \/>\n\t\t\tCasado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Separado(a)\" for=\"fld_1574495_2_opt1432735\"><input type=\"radio\" id=\"fld_1574495_2_opt1432735\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Separado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Separado(a)\" \/>\n\t\t\tSeparado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Divorciado(a)\" for=\"fld_1574495_2_opt1418034\"><input type=\"radio\" id=\"fld_1574495_2_opt1418034\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Divorciado(a)\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Divorciado(a)\" \/>\n\t\t\tDivorciado(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Vi\u00favo(a)\" for=\"fld_1574495_2_opt1437975\"><input type=\"radio\" id=\"fld_1574495_2_opt1437975\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Vi\u00favo(a)\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Vi\u00favo(a)\" \/>\n\t\t\tVi\u00favo(a)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Uni\u00e3o Est\u00e1vel\" for=\"fld_1574495_2_opt1535754\"><input type=\"radio\" id=\"fld_1574495_2_opt1535754\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Uni\u00e3o Est\u00e1vel\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Uni\u00e3o Est\u00e1vel\" \/>\n\t\t\tUni\u00e3o Est\u00e1vel\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_1574495_2_opt1603568\"><input type=\"radio\" id=\"fld_1574495_2_opt1603568\" data-field=\"fld_1574495\" class=\"fld_1574495_2 option-required\" name=\"fld_1574495\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_1574495_2\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9442215_2\" data-field-id=\"fld_9442215_2\"><\/span><\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_3473230\" class=\"form-group\" id=\"fld_3473230_2-wrap\">\r\n<label id=\"fld_3473230Label\" for=\"fld_3473230_2\" class=\"control-label\">Escolaridade <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino B\u00e1sico Incompleto\" for=\"fld_3473230_2_opt1962342\"><input type=\"radio\" id=\"fld_3473230_2_opt1962342\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino B\u00e1sico Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino B\u00e1sico Incompleto\" \/>\n\t\t\tEnsino B\u00e1sico Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino B\u00e1sico Completo\" for=\"fld_3473230_2_opt1738137\"><input type=\"radio\" id=\"fld_3473230_2_opt1738137\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino B\u00e1sico Completo\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino B\u00e1sico Completo\" \/>\n\t\t\tEnsino B\u00e1sico Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino M\u00e9dio Incompleto\" for=\"fld_3473230_2_opt1822752\"><input type=\"radio\" id=\"fld_3473230_2_opt1822752\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino M\u00e9dio Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino M\u00e9dio Incompleto\" \/>\n\t\t\tEnsino M\u00e9dio Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino M\u00e9dio Completo\" for=\"fld_3473230_2_opt1144506\"><input type=\"radio\" id=\"fld_3473230_2_opt1144506\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino M\u00e9dio Completo\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino M\u00e9dio Completo\" \/>\n\t\t\tEnsino M\u00e9dio Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino Superior Incompleto\" for=\"fld_3473230_2_opt1219521\"><input type=\"radio\" id=\"fld_3473230_2_opt1219521\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino Superior Incompleto\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino Superior Incompleto\" \/>\n\t\t\tEnsino Superior Incompleto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ensino Superior Completo\" for=\"fld_3473230_2_opt1707489\"><input type=\"radio\" id=\"fld_3473230_2_opt1707489\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Ensino Superior Completo\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Ensino Superior Completo\" \/>\n\t\t\tEnsino Superior Completo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"P\u00f3s Gradua\u00e7\u00e3o\" for=\"fld_3473230_2_opt1416217\"><input type=\"radio\" id=\"fld_3473230_2_opt1416217\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"P\u00f3s Gradua\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"P\u00f3s Gradua\u00e7\u00e3o\" \/>\n\t\t\tP\u00f3s Gradua\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Doutorado\" for=\"fld_3473230_2_opt1881869\"><input type=\"radio\" id=\"fld_3473230_2_opt1881869\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Doutorado\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Doutorado\" \/>\n\t\t\tDoutorado\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"P\u00f3s Doutorado\" for=\"fld_3473230_2_opt1550592\"><input type=\"radio\" id=\"fld_3473230_2_opt1550592\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"P\u00f3s Doutorado\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"P\u00f3s Doutorado\" \/>\n\t\t\tP\u00f3s Doutorado\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_3473230_2_opt1815639\"><input type=\"radio\" id=\"fld_3473230_2_opt1815639\" data-field=\"fld_3473230\" class=\"fld_3473230_2 option-required\" name=\"fld_3473230\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_3473230_2\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7633772_2\" data-field-id=\"fld_7633772_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-3\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9052200\" class=\"form-group\" id=\"fld_9052200_2-wrap\">\r\n\t<label id=\"fld_9052200Label\" for=\"fld_9052200_2\" class=\"control-label\">Profiss\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9052200\" class=\" form-control\" id=\"fld_9052200_2\" name=\"fld_9052200\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9052200Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-4\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4776983\" class=\"form-group\" id=\"fld_4776983_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_4776983\" id=\"fld_4776983_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_4776983\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_4776983\" id=\"fld_4776983_2_btn\" value=\"\" data-field=\"fld_4776983\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9332146\" class=\"form-group\" id=\"fld_9332146_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_9332146\" id=\"fld_9332146_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_9332146\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_9332146\" id=\"fld_9332146_2_btn\" value=\"\" data-field=\"fld_9332146\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_2\" data-formpage=\"2\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_2\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-5\"  class=\"row \"><div  class=\"col-sm-12  single\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_783295_2\" data-field-id=\"fld_783295_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-6\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_8364991\" class=\"form-group\" id=\"fld_8364991_2-wrap\">\r\n<label id=\"fld_8364991Label\" for=\"fld_8364991_2\" class=\"control-label\">Possui Filhos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_8364991_2_opt2033469\"><input type=\"radio\" id=\"fld_8364991_2_opt2033469\" data-field=\"fld_8364991\" class=\"fld_8364991_2 option-required\" name=\"fld_8364991\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_8364991_2\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o\" for=\"fld_8364991_2_opt1637251\"><input type=\"radio\" id=\"fld_8364991_2_opt1637251\" data-field=\"fld_8364991\" class=\"fld_8364991_2 option-required\" name=\"fld_8364991\" value=\"N\u00e3o\"   required=\"required\" data-radio-field=\"fld_8364991_2\" data-type=\"radio\" data-calc-value=\"N\u00e3o\" \/>\n\t\t\tN\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1576420_2\" data-field-id=\"fld_1576420_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9024547_2\" data-field-id=\"fld_9024547_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-7\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4386765\" class=\"form-group\" id=\"fld_4386765_2-wrap\">\r\n\t<label id=\"fld_4386765Label\" for=\"fld_4386765_2\" class=\"control-label\">Peso Aproximado <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '999,99'\"  required type=\"text\" data-field=\"fld_4386765\" class=\" form-control\" id=\"fld_4386765_2\" name=\"fld_4386765\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4386765Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9513699\" class=\"form-group\" id=\"fld_9513699_2-wrap\">\r\n\t<label id=\"fld_9513699Label\" for=\"fld_9513699_2\" class=\"control-label\">Altura Aproximada <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9513699\" class=\" form-control\" id=\"fld_9513699_2\" name=\"fld_9513699\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9513699Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3187774\" class=\"form-group\" id=\"fld_3187774_2-wrap\">\r\n<label id=\"fld_3187774Label\" for=\"fld_3187774_2\" class=\"control-label\">Press\u00e3o Arterial <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Baixa descontrolada\" for=\"fld_3187774_2_opt1653029\"><input type=\"radio\" id=\"fld_3187774_2_opt1653029\" data-field=\"fld_3187774\" class=\"fld_3187774_2 option-required\" name=\"fld_3187774\" value=\"Baixa descontrolada\"   required=\"required\" data-radio-field=\"fld_3187774_2\" data-type=\"radio\" data-calc-value=\"Baixa descontrolada\" \/>\n\t\t\tBaixa descontrolada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Baixa controlada\" for=\"fld_3187774_2_opt1623201\"><input type=\"radio\" id=\"fld_3187774_2_opt1623201\" data-field=\"fld_3187774\" class=\"fld_3187774_2 option-required\" name=\"fld_3187774\" value=\"Baixa controlada\"   required=\"required\" data-radio-field=\"fld_3187774_2\" data-type=\"radio\" data-calc-value=\"Baixa controlada\" \/>\n\t\t\tBaixa controlada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Normal\" for=\"fld_3187774_2_opt1373188\"><input type=\"radio\" id=\"fld_3187774_2_opt1373188\" data-field=\"fld_3187774\" class=\"fld_3187774_2 option-required\" name=\"fld_3187774\" value=\"Normal\"   required=\"required\" data-radio-field=\"fld_3187774_2\" data-type=\"radio\" data-calc-value=\"Normal\" \/>\n\t\t\tNormal\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Alta controlada\" for=\"fld_3187774_2_opt1381318\"><input type=\"radio\" id=\"fld_3187774_2_opt1381318\" data-field=\"fld_3187774\" class=\"fld_3187774_2 option-required\" name=\"fld_3187774\" value=\"Alta controlada\"   required=\"required\" data-radio-field=\"fld_3187774_2\" data-type=\"radio\" data-calc-value=\"Alta controlada\" \/>\n\t\t\tAlta controlada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Alta descontrolada\" for=\"fld_3187774_2_opt1506692\"><input type=\"radio\" id=\"fld_3187774_2_opt1506692\" data-field=\"fld_3187774\" class=\"fld_3187774_2 option-required\" name=\"fld_3187774\" value=\"Alta descontrolada\"   required=\"required\" data-radio-field=\"fld_3187774_2\" data-type=\"radio\" data-calc-value=\"Alta descontrolada\" \/>\n\t\t\tAlta descontrolada\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-8\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_2473029\" class=\"form-group\" id=\"fld_2473029_2-wrap\">\r\n\t<label id=\"fld_2473029Label\" for=\"fld_2473029_2\" class=\"control-label\">Religi\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2473029\" class=\" form-control\" id=\"fld_2473029_2\" name=\"fld_2473029\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2473029Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-9\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_9471700\" class=\"form-group\" id=\"fld_9471700_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_9471700\" id=\"fld_9471700_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_9471700\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_9471700\" id=\"fld_9471700_2_btn\" value=\"\" data-field=\"fld_9471700\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9215733\" class=\"form-group\" id=\"fld_9215733_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_9215733\" id=\"fld_9215733_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_9215733\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_9215733\" id=\"fld_9215733_2_btn\" value=\"\" data-field=\"fld_9215733\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6439464\" class=\"form-group\" id=\"fld_6439464_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_6439464\" id=\"fld_6439464_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_6439464\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_6439464\" id=\"fld_6439464_2_btn\" value=\"\" data-field=\"fld_6439464\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_3\" data-formpage=\"3\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_3\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-10\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_4594027\" class=\"form-group\" id=\"fld_4594027_2-wrap\">\r\n\t<label id=\"fld_4594027Label\" for=\"fld_4594027_2\" class=\"control-label\">Problema principal ou raz\u00f5es para a consulta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_4594027\" value=\"\" data-field=\"fld_4594027\" class=\"form-control\" id=\"fld_4594027_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_4594027Label\" aria-describedby=\"fld_4594027Caption\" ><\/textarea>\n\t\t<span id=\"fld_4594027Caption\" class=\"help-block\">Liste em ordem de import\u00e2ncia para voc\u00ea, quando come\u00e7aram, se possuem uma localiza\u00e7\u00e3o espec\u00edfica no corpo, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7586584\" class=\"form-group\" id=\"fld_7586584_2-wrap\">\r\n\t<label id=\"fld_7586584Label\" for=\"fld_7586584_2\" class=\"control-label\">Problemas adicionais ou preocupa\u00e7\u00f5es que voc\u00ea gostaria de abordar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7586584\" value=\"\" data-field=\"fld_7586584\" class=\"form-control\" id=\"fld_7586584_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7586584Label\" aria-describedby=\"fld_7586584Caption\" ><\/textarea>\n\t\t<span id=\"fld_7586584Caption\" class=\"help-block\">Nota : N\u00e3o \u00e9 poss\u00edvel resolver todos os problemas no decurso de um tratamento<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-11\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7159025\" class=\"form-group\" id=\"fld_7159025_2-wrap\">\r\n\t<label id=\"fld_7159025Label\" for=\"fld_7159025_2\" class=\"control-label\">Em quais situa\u00e7\u00f5es os sintomas se agravam? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1752501\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Ao falar\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1752501\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1752501]\"\n                                value=\"Ao falar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Ao falar\"\n                            >\n                    Ao falar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2029163\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Ao usar roupas apertadas\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2029163\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2029163]\"\n                                value=\"Ao usar roupas apertadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Ao usar roupas apertadas\"\n                            >\n                    Ao usar roupas apertadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1171381\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Quando n\u00e3o se alimenta corretamente\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1171381\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1171381]\"\n                                value=\"Quando n\u00e3o se alimenta corretamente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Quando n\u00e3o se alimenta corretamente\"\n                            >\n                    Quando n\u00e3o se alimenta corretamente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1994714\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Durante sua higiene pessoal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1994714\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1994714]\"\n                                value=\"Durante sua higiene pessoal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Durante sua higiene pessoal\"\n                            >\n                    Durante sua higiene pessoal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1108483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1108483\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1108483]\"\n                                value=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Durante a menstrua\u00e7\u00e3o em tempo frio\"\n                            >\n                    Durante a menstrua\u00e7\u00e3o em tempo frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2081411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Manh\u00e3\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2081411\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2081411]\"\n                                value=\"Manh\u00e3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Manh\u00e3\"\n                            >\n                    Manh\u00e3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1943003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Noite\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1943003\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1943003]\"\n                                value=\"Noite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Noite\"\n                            >\n                    Noite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1487906\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Na cama\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1487906\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1487906]\"\n                                value=\"Na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Na cama\"\n                            >\n                    Na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1454147\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Deitado de costas\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1454147\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1454147]\"\n                                value=\"Deitado de costas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Deitado de costas\"\n                            >\n                    Deitado de costas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1104081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Deitado no lado afetado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1104081\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1104081]\"\n                                value=\"Deitado no lado afetado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Deitado no lado afetado\"\n                            >\n                    Deitado no lado afetado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2029059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2029059\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2029059]\"\n                                value=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Quando muda de posi\u00e7\u00e3o na cama\"\n                            >\n                    Quando muda de posi\u00e7\u00e3o na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1221576\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Durante o repouso\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1221576\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1221576]\"\n                                value=\"Durante o repouso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Durante o repouso\"\n                            >\n                    Durante o repouso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1580283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Durante o sono\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1580283\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1580283]\"\n                                value=\"Durante o sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Durante o sono\"\n                            >\n                    Durante o sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1653981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Durante exerc\u00edcios\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1653981\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1653981]\"\n                                value=\"Durante exerc\u00edcios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Durante exerc\u00edcios\"\n                            >\n                    Durante exerc\u00edcios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2031475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Em clima frio\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2031475\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2031475]\"\n                                value=\"Em clima frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Em clima frio\"\n                            >\n                    Em clima frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2096252\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Em clima \u00famido\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2096252\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2096252]\"\n                                value=\"Em clima \u00famido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Em clima \u00famido\"\n                            >\n                    Em clima \u00famido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1879459\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Mudan\u00e7as de temperatura\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1879459\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1879459]\"\n                                value=\"Mudan\u00e7as de temperatura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Mudan\u00e7as de temperatura\"\n                            >\n                    Mudan\u00e7as de temperatura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1742522\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Antes de um temporal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1742522\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1742522]\"\n                                value=\"Antes de um temporal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Antes de um temporal\"\n                            >\n                    Antes de um temporal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1646665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Depois de um temporal\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1646665\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1646665]\"\n                                value=\"Depois de um temporal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Depois de um temporal\"\n                            >\n                    Depois de um temporal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1833258\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Na primavera\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1833258\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1833258]\"\n                                value=\"Na primavera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Na primavera\"\n                            >\n                    Na primavera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1953926\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"No ver\u00e3o\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1953926\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1953926]\"\n                                value=\"No ver\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"No ver\u00e3o\"\n                            >\n                    No ver\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1100701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"No outono\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1100701\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1100701]\"\n                                value=\"No outono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"No outono\"\n                            >\n                    No outono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1624371\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"No inverno\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1624371\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1624371]\"\n                                value=\"No inverno\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"No inverno\"\n                            >\n                    No inverno                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1986441\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Exposto a luz do Sol\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1986441\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1986441]\"\n                                value=\"Exposto a luz do Sol\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Exposto a luz do Sol\"\n                            >\n                    Exposto a luz do Sol                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1421716\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Na praia ou no mar\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1421716\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1421716]\"\n                                value=\"Na praia ou no mar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Na praia ou no mar\"\n                            >\n                    Na praia ou no mar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1923481\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Em ambiente quente ou abafado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1923481\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1923481]\"\n                                value=\"Em ambiente quente ou abafado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Em ambiente quente ou abafado\"\n                            >\n                    Em ambiente quente ou abafado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2035402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Em ambiente fechado ou lotado\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2035402\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2035402]\"\n                                value=\"Em ambiente fechado ou lotado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Em ambiente fechado ou lotado\"\n                            >\n                    Em ambiente fechado ou lotado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt2089671\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Cheiro de tabaco\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt2089671\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt2089671]\"\n                                value=\"Cheiro de tabaco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Cheiro de tabaco\"\n                            >\n                    Cheiro de tabaco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7159025_2_opt1936618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7159025_2\" data-parsley-multiple=\"fld_7159025_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7159025\"\n                                id=\"fld_7159025_2_opt1936618\"\n                                class=\"fld_7159025_2 option-required\"\n                                name=\"fld_7159025[opt1936618]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7159025_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3885880_2\" data-field-id=\"fld_3885880_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6367522\" class=\"form-group\" id=\"fld_6367522_2-wrap\">\r\n\t<label id=\"fld_6367522Label\" for=\"fld_6367522_2\" class=\"control-label\">Em quais situa\u00e7\u00f5es os sintomas melhoram? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1339328\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Quando se alimenta\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1339328\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1339328]\"\n                                value=\"Quando se alimenta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Quando se alimenta\"\n                            >\n                    Quando se alimenta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1968472\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Quando fica sozinho\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1968472\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1968472]\"\n                                value=\"Quando fica sozinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Quando fica sozinho\"\n                            >\n                    Quando fica sozinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1183368\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Ao ouvir m\u00fasica\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1183368\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1183368]\"\n                                value=\"Ao ouvir m\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Ao ouvir m\u00fasica\"\n                            >\n                    Ao ouvir m\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1893677\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Aplicando press\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1893677\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1893677]\"\n                                value=\"Aplicando press\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Aplicando press\u00e3o\"\n                            >\n                    Aplicando press\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1415624\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Aplicando compressas frias\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1415624\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1415624]\"\n                                value=\"Aplicando compressas frias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Aplicando compressas frias\"\n                            >\n                    Aplicando compressas frias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1298411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Aplicando compressas quentes\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1298411\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1298411]\"\n                                value=\"Aplicando compressas quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Aplicando compressas quentes\"\n                            >\n                    Aplicando compressas quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1128783\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Ao dobrar-se ou contorcer-se\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1128783\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1128783]\"\n                                value=\"Ao dobrar-se ou contorcer-se\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Ao dobrar-se ou contorcer-se\"\n                            >\n                    Ao dobrar-se ou contorcer-se                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1260413\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Virando para tr\u00e1s\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1260413\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1260413]\"\n                                value=\"Virando para tr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Virando para tr\u00e1s\"\n                            >\n                    Virando para tr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1443326\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Manh\u00e3\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1443326\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1443326]\"\n                                value=\"Manh\u00e3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Manh\u00e3\"\n                            >\n                    Manh\u00e3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1956207\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Noite\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1956207\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1956207]\"\n                                value=\"Noite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Noite\"\n                            >\n                    Noite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1833104\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Madrugada\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1833104\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1833104]\"\n                                value=\"Madrugada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Madrugada\"\n                            >\n                    Madrugada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1546340\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Durante o repouso\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1546340\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1546340]\"\n                                value=\"Durante o repouso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Durante o repouso\"\n                            >\n                    Durante o repouso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1417686\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Destapando os p\u00e9s na cama\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1417686\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1417686]\"\n                                value=\"Destapando os p\u00e9s na cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Destapando os p\u00e9s na cama\"\n                            >\n                    Destapando os p\u00e9s na cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1404970\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Abrindo uma janela\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1404970\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1404970]\"\n                                value=\"Abrindo uma janela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Abrindo uma janela\"\n                            >\n                    Abrindo uma janela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1406169\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Ao ar livre\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1406169\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1406169]\"\n                                value=\"Ao ar livre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Ao ar livre\"\n                            >\n                    Ao ar livre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1206869\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Exposto a luz do Sol\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1206869\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1206869]\"\n                                value=\"Exposto a luz do Sol\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Exposto a luz do Sol\"\n                            >\n                    Exposto a luz do Sol                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1102018\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Durante o ver\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1102018\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1102018]\"\n                                value=\"Durante o ver\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Durante o ver\u00e3o\"\n                            >\n                    Durante o ver\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1209480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Na praia ou no mar\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1209480\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1209480]\"\n                                value=\"Na praia ou no mar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Na praia ou no mar\"\n                            >\n                    Na praia ou no mar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt2088186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Ao mudar-se\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt2088186\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt2088186]\"\n                                value=\"Ao mudar-se\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Ao mudar-se\"\n                            >\n                    Ao mudar-se                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1485411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1485411\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1485411]\"\n                                value=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Quando inicia a menstrua\u00e7\u00e3o\"\n                            >\n                    Quando inicia a menstrua\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6367522_2_opt1919798\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6367522_2\" data-parsley-multiple=\"fld_6367522_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6367522\"\n                                id=\"fld_6367522_2_opt1919798\"\n                                class=\"fld_6367522_2 option-required\"\n                                name=\"fld_6367522[opt1919798]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6367522_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6650295_2\" data-field-id=\"fld_6650295_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-12\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_5341049\" class=\"form-group\" id=\"fld_5341049_2-wrap\">\r\n\t<label id=\"fld_5341049Label\" for=\"fld_5341049_2\" class=\"control-label\">Medicamentos alop\u00e1ticos em uso <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5341049\" value=\"\" data-field=\"fld_5341049\" class=\"form-control\" id=\"fld_5341049_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_5341049Label\" aria-describedby=\"fld_5341049Caption\" ><\/textarea>\n\t\t<span id=\"fld_5341049Caption\" class=\"help-block\">A quanto tempo usa, qual a dose e numero de vezes por dia e como est\u00e1 se sentindo com o uso<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2967108\" class=\"form-group\" id=\"fld_2967108_2-wrap\">\r\n\t<label id=\"fld_2967108Label\" for=\"fld_2967108_2\" class=\"control-label\">Medicamentos alop\u00e1ticos que j\u00e1 utilizou no passado <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2967108\" value=\"\" data-field=\"fld_2967108\" class=\"form-control\" id=\"fld_2967108_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2967108Label\" aria-describedby=\"fld_2967108Caption\" ><\/textarea>\n\t\t<span id=\"fld_2967108Caption\" class=\"help-block\">A quanto tempo usou, qual a dose e numero de vezes por dia e como se sentiu com o uso (Se lembrar)<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6796582\" class=\"form-group\" id=\"fld_6796582_2-wrap\">\r\n\t<label id=\"fld_6796582Label\" for=\"fld_6796582_2\" class=\"control-label\">Quais vacinas voc\u00ea recebeu? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6796582\" value=\"\" data-field=\"fld_6796582\" class=\"form-control\" id=\"fld_6796582_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6796582Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9466148\" class=\"form-group\" id=\"fld_9466148_2-wrap\">\r\n\t<label id=\"fld_9466148Label\" for=\"fld_9466148_2\" class=\"control-label\">Fitoter\u00e1picos, homeop\u00e1ticos, vitaminas e suplementos em uso <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9466148\" value=\"\" data-field=\"fld_9466148\" class=\"form-control\" id=\"fld_9466148_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9466148Label\" aria-describedby=\"fld_9466148Caption\" ><\/textarea>\n\t\t<span id=\"fld_9466148Caption\" class=\"help-block\">A quanto tempo usa, qual a dose e n\u00famero de vezes por dia<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-13\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8952750\" class=\"form-group\" id=\"fld_8952750_2-wrap\">\r\n\t<label id=\"fld_8952750Label\" for=\"fld_8952750_2\" class=\"control-label\">Dispositivos que voc\u00ea usa <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1818115\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"\u00d3culos\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1818115\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1818115]\"\n                                value=\"\u00d3culos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"\u00d3culos\"\n                            >\n                    \u00d3culos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1813301\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Lente de contato\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1813301\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1813301]\"\n                                value=\"Lente de contato\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Lente de contato\"\n                            >\n                    Lente de contato                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1192683\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1192683\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1192683]\"\n                                value=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Obtura\u00e7\u00e3o ou implante dent\u00e1rio\"\n                            >\n                    Obtura\u00e7\u00e3o ou implante dent\u00e1rio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt2030644\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Dentadura\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt2030644\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt2030644]\"\n                                value=\"Dentadura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Dentadura\"\n                            >\n                    Dentadura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1453780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Aparelho auditivo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1453780\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1453780]\"\n                                value=\"Aparelho auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Aparelho auditivo\"\n                            >\n                    Aparelho auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1689357\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Pr\u00f3tese ou membro artificial\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1689357\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1689357]\"\n                                value=\"Pr\u00f3tese ou membro artificial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Pr\u00f3tese ou membro artificial\"\n                            >\n                    Pr\u00f3tese ou membro artificial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1120655\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Marcapasso\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1120655\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1120655]\"\n                                value=\"Marcapasso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Marcapasso\"\n                            >\n                    Marcapasso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1967343\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Stents card\u00edacos, vasculares ou uretrais\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1967343\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1967343]\"\n                                value=\"Stents card\u00edacos, vasculares ou uretrais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Stents card\u00edacos, vasculares ou uretrais\"\n                            >\n                    Stents card\u00edacos, vasculares ou uretrais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1399409\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Aparelho contraceptivo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1399409\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1399409]\"\n                                value=\"Aparelho contraceptivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Aparelho contraceptivo\"\n                            >\n                    Aparelho contraceptivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1179279\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Biochip\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1179279\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1179279]\"\n                                value=\"Biochip\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Biochip\"\n                            >\n                    Biochip                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1191531\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1191531\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1191531]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8952750_2_opt1608887\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8952750_2\" data-parsley-multiple=\"fld_8952750_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8952750\"\n                                id=\"fld_8952750_2_opt1608887\"\n                                class=\"fld_8952750_2 option-required\"\n                                name=\"fld_8952750[opt1608887]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8952750_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1530349_2\" data-field-id=\"fld_1530349_2\"><div data-field-wrapper=\"fld_1530349\" class=\"form-group\" id=\"fld_1530349_2-wrap\">\r\n\t<label id=\"fld_1530349Label\" for=\"fld_1530349_2\" class=\"control-label\">Complementar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1530349\" class=\" form-control\" id=\"fld_1530349_2\" name=\"fld_1530349\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1530349Label\" aria-describedby=\"fld_1530349Caption\" >\t\t<span id=\"fld_1530349Caption\" class=\"help-block\">Ex : Se possui obtura\u00e7\u00f5es, quantas? Se possui pr\u00f3tese ou membros artificiais, qual?<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5652515\" class=\"form-group\" id=\"fld_5652515_2-wrap\">\r\n\t<label id=\"fld_5652515Label\" for=\"fld_5652515_2\" class=\"control-label\">Hist\u00f3rico M\u00e9dico <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1365348\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Doen\u00e7a\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1365348\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1365348]\"\n                                value=\"Doen\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Doen\u00e7a\"\n                            >\n                    Doen\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1263132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Les\u00e3o\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1263132\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1263132]\"\n                                value=\"Les\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Les\u00e3o\"\n                            >\n                    Les\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1836715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Interna\u00e7\u00e3o\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1836715\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1836715]\"\n                                value=\"Interna\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Interna\u00e7\u00e3o\"\n                            >\n                    Interna\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1721430\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Cirurgia\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1721430\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1721430]\"\n                                value=\"Cirurgia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Cirurgia\"\n                            >\n                    Cirurgia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt2026537\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Trauma f\u00edsico\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt2026537\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt2026537]\"\n                                value=\"Trauma f\u00edsico\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Trauma f\u00edsico\"\n                            >\n                    Trauma f\u00edsico                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1167051\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1167051\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1167051]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5652515_2_opt1694343\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5652515_2\" data-parsley-multiple=\"fld_5652515_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5652515\"\n                                id=\"fld_5652515_2_opt1694343\"\n                                class=\"fld_5652515_2 option-required\"\n                                name=\"fld_5652515[opt1694343]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5652515_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3043002_2\" data-field-id=\"fld_3043002_2\"><div data-field-wrapper=\"fld_3043002\" class=\"form-group\" id=\"fld_3043002_2-wrap\">\r\n\t<label id=\"fld_3043002Label\" for=\"fld_3043002_2\" class=\"control-label\">Descreva o(s) hist\u00f3rico(s) m\u00e9dico(s) marcado(s) acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3043002\" value=\"\" data-field=\"fld_3043002\" class=\"form-control\" id=\"fld_3043002_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3043002Label\" aria-describedby=\"fld_3043002Caption\" ><\/textarea>\n\t\t<span id=\"fld_3043002Caption\" class=\"help-block\">Motivo, m\u00eas e ano, tempo de interna\u00e7\u00e3o, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-14\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4659334\" class=\"form-group\" id=\"fld_4659334_2-wrap\">\r\n\t<label id=\"fld_4659334Label\" for=\"fld_4659334_2\" class=\"control-label\">Alergias conhecidas <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1120778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1120778\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1120778]\"\n                                value=\"Alimentos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"Alimentos\"\n                            >\n                    Alimentos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1606026\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"P\u00f3len\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1606026\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1606026]\"\n                                value=\"P\u00f3len\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"P\u00f3len\"\n                            >\n                    P\u00f3len                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1091707\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"Odores\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1091707\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1091707]\"\n                                value=\"Odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"Odores\"\n                            >\n                    Odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1068315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1068315\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1068315]\"\n                                value=\"Rem\u00e9dios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"Rem\u00e9dios\"\n                            >\n                    Rem\u00e9dios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1456006\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"Animais\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1456006\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1456006]\"\n                                value=\"Animais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"Animais\"\n                            >\n                    Animais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1483014\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1483014\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1483014]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4659334_2_opt1736147\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4659334_2\" data-parsley-multiple=\"fld_4659334_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4659334\"\n                                id=\"fld_4659334_2_opt1736147\"\n                                class=\"fld_4659334_2 option-required\"\n                                name=\"fld_4659334[opt1736147]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4659334_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1619118_2\" data-field-id=\"fld_1619118_2\"><div data-field-wrapper=\"fld_1619118\" class=\"form-group\" id=\"fld_1619118_2-wrap\">\r\n\t<label id=\"fld_1619118Label\" for=\"fld_1619118_2\" class=\"control-label\">Fale sobre as alergias marcadas acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1619118\" value=\"\" data-field=\"fld_1619118\" class=\"form-control\" id=\"fld_1619118_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1619118Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-15\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_5814596\" class=\"form-group\" id=\"fld_5814596_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_5814596\" id=\"fld_5814596_2\" value=\"Pagina Anterior\" data-field=\"fld_5814596\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_5814596\" id=\"fld_5814596_2_btn\" value=\"\" data-field=\"fld_5814596\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6819459\" class=\"form-group\" id=\"fld_6819459_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_6819459\" id=\"fld_6819459_2\" value=\"Pagina Seguinte\" data-field=\"fld_6819459\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_6819459\" id=\"fld_6819459_2_btn\" value=\"\" data-field=\"fld_6819459\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4180018\" class=\"form-group\" id=\"fld_4180018_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_4180018\" id=\"fld_4180018_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_4180018\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_4180018\" id=\"fld_4180018_2_btn\" value=\"\" data-field=\"fld_4180018\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_4\" data-formpage=\"4\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_4\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-16\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8514796\" class=\"form-group\" id=\"fld_8514796_2-wrap\">\r\n<label id=\"fld_8514796Label\" for=\"fld_8514796_2\" class=\"control-label\">Como \u00e9 o seu relacionamento amoroso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Feliz\" for=\"fld_8514796_2_opt1823098\"><input type=\"radio\" id=\"fld_8514796_2_opt1823098\" data-field=\"fld_8514796\" class=\"fld_8514796_2 option-required\" name=\"fld_8514796\" value=\"Feliz\"   required=\"required\" data-radio-field=\"fld_8514796_2\" data-type=\"radio\" data-calc-value=\"Feliz\" \/>\n\t\t\tFeliz\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Exigente\" for=\"fld_8514796_2_opt1575060\"><input type=\"radio\" id=\"fld_8514796_2_opt1575060\" data-field=\"fld_8514796\" class=\"fld_8514796_2 option-required\" name=\"fld_8514796\" value=\"Exigente\"   required=\"required\" data-radio-field=\"fld_8514796_2\" data-type=\"radio\" data-calc-value=\"Exigente\" \/>\n\t\t\tExigente\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ciumento\" for=\"fld_8514796_2_opt1530874\"><input type=\"radio\" id=\"fld_8514796_2_opt1530874\" data-field=\"fld_8514796\" class=\"fld_8514796_2 option-required\" name=\"fld_8514796\" value=\"Ciumento\"   required=\"required\" data-radio-field=\"fld_8514796_2\" data-type=\"radio\" data-calc-value=\"Ciumento\" \/>\n\t\t\tCiumento\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Infeliz\" for=\"fld_8514796_2_opt1840198\"><input type=\"radio\" id=\"fld_8514796_2_opt1840198\" data-field=\"fld_8514796\" class=\"fld_8514796_2 option-required\" name=\"fld_8514796\" value=\"Infeliz\"   required=\"required\" data-radio-field=\"fld_8514796_2\" data-type=\"radio\" data-calc-value=\"Infeliz\" \/>\n\t\t\tInfeliz\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_8514796_2_opt1362757\"><input type=\"radio\" id=\"fld_8514796_2_opt1362757\" data-field=\"fld_8514796\" class=\"fld_8514796_2 option-required\" name=\"fld_8514796\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_8514796_2\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7494269_2\" data-field-id=\"fld_7494269_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_7513570\" class=\"form-group\" id=\"fld_7513570_2-wrap\">\r\n\t<label id=\"fld_7513570Label\" for=\"fld_7513570_2\" class=\"control-label\">Grandes tens\u00f5es emocionais nos \u00faltimos 2 anos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt2020930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Dinheiro\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt2020930\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt2020930]\"\n                                value=\"Dinheiro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Dinheiro\"\n                            >\n                    Dinheiro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt1233977\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Emprego\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt1233977\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt1233977]\"\n                                value=\"Emprego\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Emprego\"\n                            >\n                    Emprego                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt1176090\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Casamento\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt1176090\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt1176090]\"\n                                value=\"Casamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Casamento\"\n                            >\n                    Casamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt1634599\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Relacionamento familiar\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt1634599\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt1634599]\"\n                                value=\"Relacionamento familiar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Relacionamento familiar\"\n                            >\n                    Relacionamento familiar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt1834216\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt1834216\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt1834216]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7513570_2_opt1818458\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7513570_2\" data-parsley-multiple=\"fld_7513570_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7513570\"\n                                id=\"fld_7513570_2_opt1818458\"\n                                class=\"fld_7513570_2 option-required\"\n                                name=\"fld_7513570[opt1818458]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7513570_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6094755_2\" data-field-id=\"fld_6094755_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-17\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_3665933\" class=\"form-group\" id=\"fld_3665933_2-wrap\">\r\n\t<label id=\"fld_3665933Label\" for=\"fld_3665933_2\" class=\"control-label\">Hist\u00f3rico de viagens pertinentes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3665933\" value=\"\" data-field=\"fld_3665933\" class=\"form-control\" id=\"fld_3665933_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3665933Label\" aria-describedby=\"fld_3665933Caption\" ><\/textarea>\n\t\t<span id=\"fld_3665933Caption\" class=\"help-block\">Ao exterior, regi\u00f5es com epidemias, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-18\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5873470\" class=\"form-group\" id=\"fld_5873470_2-wrap\">\r\n\t<label id=\"fld_5873470Label\" for=\"fld_5873470_2\" class=\"control-label\">Possui algum v\u00edcio? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1731755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"\u00c1lcool\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1731755\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1731755]\"\n                                value=\"\u00c1lcool\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"\u00c1lcool\"\n                            >\n                    \u00c1lcool                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1674018\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Caf\u00e9\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1674018\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1674018]\"\n                                value=\"Caf\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Caf\u00e9\"\n                            >\n                    Caf\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1499379\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Chocolate\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1499379\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1499379]\"\n                                value=\"Chocolate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Chocolate\"\n                            >\n                    Chocolate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1788199\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Cigarro, charuto ou cachimbo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1788199\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1788199]\"\n                                value=\"Cigarro, charuto ou cachimbo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Cigarro, charuto ou cachimbo\"\n                            >\n                    Cigarro, charuto ou cachimbo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1576634\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Sexo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1576634\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1576634]\"\n                                value=\"Sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Sexo\"\n                            >\n                    Sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1594040\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios diet\u00e9ticos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1594040\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1594040]\"\n                                value=\"Rem\u00e9dios diet\u00e9ticos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Rem\u00e9dios diet\u00e9ticos\"\n                            >\n                    Rem\u00e9dios diet\u00e9ticos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1664849\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Rem\u00e9dios sedativos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1664849\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1664849]\"\n                                value=\"Rem\u00e9dios sedativos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Rem\u00e9dios sedativos\"\n                            >\n                    Rem\u00e9dios sedativos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1138925\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Narc\u00f3ticos\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1138925\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1138925]\"\n                                value=\"Narc\u00f3ticos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Narc\u00f3ticos\"\n                            >\n                    Narc\u00f3ticos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1580382\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Drogas\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1580382\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1580382]\"\n                                value=\"Drogas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Drogas\"\n                            >\n                    Drogas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1968125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1968125\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1968125]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5873470_2_opt1902139\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5873470_2\" data-parsley-multiple=\"fld_5873470_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5873470\"\n                                id=\"fld_5873470_2_opt1902139\"\n                                class=\"fld_5873470_2 option-required\"\n                                name=\"fld_5873470[opt1902139]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5873470_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2575749_2\" data-field-id=\"fld_2575749_2\"><div data-field-wrapper=\"fld_2575749\" class=\"form-group\" id=\"fld_2575749_2-wrap\">\r\n\t<label id=\"fld_2575749Label\" for=\"fld_2575749_2\" class=\"control-label\">Quais? Tem inten\u00e7\u00e3o de parar o uso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2575749\" value=\"\" data-field=\"fld_2575749\" class=\"form-control\" id=\"fld_2575749_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2575749Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7520435_2\" data-field-id=\"fld_7520435_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-19\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9183728\" class=\"form-group\" id=\"fld_9183728_2-wrap\">\r\n\t<label id=\"fld_9183728Label\" for=\"fld_9183728_2\" class=\"control-label\">Como lida com o estresse? Precisa de ajuda quanto a isso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9183728\" value=\"\" data-field=\"fld_9183728\" class=\"form-control\" id=\"fld_9183728_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9183728Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7404788\" class=\"form-group\" id=\"fld_7404788_2-wrap\">\r\n\t<label id=\"fld_7404788Label\" for=\"fld_7404788_2\" class=\"control-label\">Se exercita regularmente? Se n\u00e3o, porqu\u00ea? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7404788\" value=\"\" data-field=\"fld_7404788\" class=\"form-control\" id=\"fld_7404788_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7404788Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_4222683\" class=\"form-group\" id=\"fld_4222683_2-wrap\">\r\n\t<label id=\"fld_4222683Label\" for=\"fld_4222683_2\" class=\"control-label\">Voc\u00ea gosta de seu trabalho? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_4222683\" value=\"\" data-field=\"fld_4222683\" class=\"form-control\" id=\"fld_4222683_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_4222683Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3879322\" class=\"form-group\" id=\"fld_3879322_2-wrap\">\r\n\t<label id=\"fld_3879322Label\" for=\"fld_3879322_2\" class=\"control-label\">Voc\u00ea reserva tempo para descontrair e relaxar? Se n\u00e3o, porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3879322\" value=\"\" data-field=\"fld_3879322\" class=\"form-control\" id=\"fld_3879322_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3879322Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5641702\" class=\"form-group\" id=\"fld_5641702_2-wrap\">\r\n\t<label id=\"fld_5641702Label\" for=\"fld_5641702_2\" class=\"control-label\">Como \u00e9 seu sono? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5641702\" value=\"\" data-field=\"fld_5641702\" class=\"form-control\" id=\"fld_5641702_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_5641702Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6116219\" class=\"form-group\" id=\"fld_6116219_2-wrap\">\r\n\t<label id=\"fld_6116219Label\" for=\"fld_6116219_2\" class=\"control-label\">Est\u00e1 satisfeito com sua vida sexual? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6116219\" value=\"\" data-field=\"fld_6116219\" class=\"form-control\" id=\"fld_6116219_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6116219Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9783363\" class=\"form-group\" id=\"fld_9783363_2-wrap\">\r\n\t<label id=\"fld_9783363Label\" for=\"fld_9783363_2\" class=\"control-label\">Est\u00e1 satisfeito com sua vida social? Porque? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9783363\" value=\"\" data-field=\"fld_9783363\" class=\"form-control\" id=\"fld_9783363_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9783363Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_8755164\" class=\"form-group\" id=\"fld_8755164_2-wrap\">\r\n\t<label id=\"fld_8755164Label\" for=\"fld_8755164_2\" class=\"control-label\">Est\u00e1 satisfeito com sua vida religiosa\/espiritual? Porque?<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_8755164\" value=\"\" data-field=\"fld_8755164\" class=\"form-control\" id=\"fld_8755164_2\" rows=\"4\"    aria-labelledby=\"fld_8755164Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-20\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4636684\" class=\"form-group\" id=\"fld_4636684_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_4636684\" id=\"fld_4636684_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_4636684\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_4636684\" id=\"fld_4636684_2_btn\" value=\"\" data-field=\"fld_4636684\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_372783\" class=\"form-group\" id=\"fld_372783_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_372783\" id=\"fld_372783_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_372783\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_372783\" id=\"fld_372783_2_btn\" value=\"\" data-field=\"fld_372783\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_5043437\" class=\"form-group\" id=\"fld_5043437_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_5043437\" id=\"fld_5043437_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_5043437\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_5043437\" id=\"fld_5043437_2_btn\" value=\"\" data-field=\"fld_5043437\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_5\" data-formpage=\"5\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_5\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-21\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_544334\" class=\"form-group\" id=\"fld_544334_2-wrap\">\r\n<label id=\"fld_544334Label\" for=\"fld_544334_2\" class=\"control-label\">Como est\u00e1 seu apetite? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Bom\" for=\"fld_544334_2_opt1918307\"><input type=\"radio\" id=\"fld_544334_2_opt1918307\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Bom\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Bom\" \/>\n\t\t\tBom\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Diminuiu\" for=\"fld_544334_2_opt1108432\"><input type=\"radio\" id=\"fld_544334_2_opt1108432\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Diminuiu\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Diminuiu\" \/>\n\t\t\tDiminuiu\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Nunca sente fome\" for=\"fld_544334_2_opt1133680\"><input type=\"radio\" id=\"fld_544334_2_opt1133680\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Nunca sente fome\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Nunca sente fome\" \/>\n\t\t\tNunca sente fome\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Est\u00e1 sempre com fome\" for=\"fld_544334_2_opt1576919\"><input type=\"radio\" id=\"fld_544334_2_opt1576919\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Est\u00e1 sempre com fome\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Est\u00e1 sempre com fome\" \/>\n\t\t\tEst\u00e1 sempre com fome\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\" for=\"fld_544334_2_opt1672276\"><input type=\"radio\" id=\"fld_544334_2_opt1672276\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"N\u00e3o consegue terminar a refei\u00e7\u00e3o\" \/>\n\t\t\tN\u00e3o consegue terminar a refei\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\" for=\"fld_544334_2_opt2007610\"><input type=\"radio\" id=\"fld_544334_2_opt2007610\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Fome logo ap\u00f3s a refei\u00e7\u00e3o\" \/>\n\t\t\tFome logo ap\u00f3s a refei\u00e7\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Outro\" for=\"fld_544334_2_opt1266308\"><input type=\"radio\" id=\"fld_544334_2_opt1266308\" data-field=\"fld_544334\" class=\"fld_544334_2 option-required\" name=\"fld_544334\" value=\"Outro\"   required=\"required\" data-radio-field=\"fld_544334_2\" data-type=\"radio\" data-calc-value=\"Outro\" \/>\n\t\t\tOutro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_977328_2\" data-field-id=\"fld_977328_2\"><\/span><div data-field-wrapper=\"fld_3226139\" class=\"form-group\" id=\"fld_3226139_2-wrap\">\r\n\t<label id=\"fld_3226139Label\" for=\"fld_3226139_2\" class=\"control-label\">Ingere cafeina? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1883903\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Caf\u00e9\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1883903\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1883903]\"\n                                value=\"Caf\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Caf\u00e9\"\n                            >\n                    Caf\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1903978\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Ch\u00e1\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1903978\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1903978]\"\n                                value=\"Ch\u00e1\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Ch\u00e1\"\n                            >\n                    Ch\u00e1                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1475464\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Erva Mate\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1475464\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1475464]\"\n                                value=\"Erva Mate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Erva Mate\"\n                            >\n                    Erva Mate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1688200\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Refrigerante\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1688200\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1688200]\"\n                                value=\"Refrigerante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Refrigerante\"\n                            >\n                    Refrigerante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1768670\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Balas\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1768670\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1768670]\"\n                                value=\"Balas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Balas\"\n                            >\n                    Balas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1218190\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o consumo\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1218190\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1218190]\"\n                                value=\"N\u00e3o consumo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"N\u00e3o consumo\"\n                            >\n                    N\u00e3o consumo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3226139_2_opt1382706\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3226139_2\" data-parsley-multiple=\"fld_3226139_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3226139\"\n                                id=\"fld_3226139_2_opt1382706\"\n                                class=\"fld_3226139_2 option-required\"\n                                name=\"fld_3226139[opt1382706]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3226139_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2985878_2\" data-field-id=\"fld_2985878_2\"><\/span><div data-field-wrapper=\"fld_6437431\" class=\"form-group\" id=\"fld_6437431_2-wrap\">\r\n<label id=\"fld_6437431Label\" for=\"fld_6437431_2\" class=\"control-label\">Ingere bebidas alco\u00f3licas? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_6437431_2_opt1452404\"><input type=\"radio\" id=\"fld_6437431_2_opt1452404\" data-field=\"fld_6437431\" class=\"fld_6437431_2 option-required\" name=\"fld_6437431\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_6437431_2\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o, mas j\u00e1 ingeri\" for=\"fld_6437431_2_opt1978495\"><input type=\"radio\" id=\"fld_6437431_2_opt1978495\" data-field=\"fld_6437431\" class=\"fld_6437431_2 option-required\" name=\"fld_6437431\" value=\"N\u00e3o, mas j\u00e1 ingeri\"   required=\"required\" data-radio-field=\"fld_6437431_2\" data-type=\"radio\" data-calc-value=\"N\u00e3o, mas j\u00e1 ingeri\" \/>\n\t\t\tN\u00e3o, mas j\u00e1 ingeri\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o, nunca ingeri\" for=\"fld_6437431_2_opt2025664\"><input type=\"radio\" id=\"fld_6437431_2_opt2025664\" data-field=\"fld_6437431\" class=\"fld_6437431_2 option-required\" name=\"fld_6437431\" value=\"N\u00e3o, nunca ingeri\"   required=\"required\" data-radio-field=\"fld_6437431_2\" data-type=\"radio\" data-calc-value=\"N\u00e3o, nunca ingeri\" \/>\n\t\t\tN\u00e3o, nunca ingeri\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_950222_2\" data-field-id=\"fld_950222_2\"><div data-field-wrapper=\"fld_950222\" class=\"form-group\" id=\"fld_950222_2-wrap\">\r\n\t<label id=\"fld_950222Label\" for=\"fld_950222_2\" class=\"control-label\">Descreva? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_950222\" value=\"\" data-field=\"fld_950222\" class=\"form-control\" id=\"fld_950222_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_950222Label\" aria-describedby=\"fld_950222Caption\" ><\/textarea>\n\t\t<span id=\"fld_950222Caption\" class=\"help-block\">Qual bebida e quantas doses ou a quanto tempo parou<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1672428\" class=\"form-group\" id=\"fld_1672428_2-wrap\">\r\n\t<label id=\"fld_1672428Label\" for=\"fld_1672428_2\" class=\"control-label\">Descreva seu caf\u00e9 da manh\u00e3 <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1672428\" value=\"\" data-field=\"fld_1672428\" class=\"form-control\" id=\"fld_1672428_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1672428Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1134414\" class=\"form-group\" id=\"fld_1134414_2-wrap\">\r\n\t<label id=\"fld_1134414Label\" for=\"fld_1134414_2\" class=\"control-label\">Descreva seu lanche da manh\u00e3 <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1134414\" value=\"\" data-field=\"fld_1134414\" class=\"form-control\" id=\"fld_1134414_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1134414Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_8285721\" class=\"form-group\" id=\"fld_8285721_2-wrap\">\r\n\t<label id=\"fld_8285721Label\" for=\"fld_8285721_2\" class=\"control-label\">Descreva seu almo\u00e7o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_8285721\" value=\"\" data-field=\"fld_8285721\" class=\"form-control\" id=\"fld_8285721_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_8285721Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6678282\" class=\"form-group\" id=\"fld_6678282_2-wrap\">\r\n\t<label id=\"fld_6678282Label\" for=\"fld_6678282_2\" class=\"control-label\">Descreva seu lanche da tarde <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_6678282\" value=\"\" data-field=\"fld_6678282\" class=\"form-control\" id=\"fld_6678282_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_6678282Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1152584\" class=\"form-group\" id=\"fld_1152584_2-wrap\">\r\n\t<label id=\"fld_1152584Label\" for=\"fld_1152584_2\" class=\"control-label\">Descreva sua janta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1152584\" value=\"\" data-field=\"fld_1152584\" class=\"form-control\" id=\"fld_1152584_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1152584Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5536810\" class=\"form-group\" id=\"fld_5536810_2-wrap\">\r\n\t<label id=\"fld_5536810Label\" for=\"fld_5536810_2\" class=\"control-label\">Descreva, se possuir, outras refei\u00e7\u00f5es feitas no dia<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5536810\" value=\"\" data-field=\"fld_5536810\" class=\"form-control\" id=\"fld_5536810_2\" rows=\"4\"    aria-labelledby=\"fld_5536810Label\" aria-describedby=\"fld_5536810Caption\" ><\/textarea>\n\t\t<span id=\"fld_5536810Caption\" class=\"help-block\">Refei\u00e7\u00f5es foras as citadas acima<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-22\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5437915\" class=\"form-group\" id=\"fld_5437915_2-wrap\">\r\n\t<label id=\"fld_5437915Label\" for=\"fld_5437915_2\" class=\"control-label\">Voc\u00ea possui algum desejo forte dos seguintes alimentos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1058520\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos a temperatura ambiente\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1058520\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1058520]\"\n                                value=\"Alimentos a temperatura ambiente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos a temperatura ambiente\"\n                            >\n                    Alimentos a temperatura ambiente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1312447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos quentes\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1312447\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1312447]\"\n                                value=\"Alimentos quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos quentes\"\n                            >\n                    Alimentos quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1081833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos frios\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1081833\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1081833]\"\n                                value=\"Alimentos frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos frios\"\n                            >\n                    Alimentos frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1753842\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos gordurosos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1753842\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1753842]\"\n                                value=\"Alimentos gordurosos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos gordurosos\"\n                            >\n                    Alimentos gordurosos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1341831\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos picantes\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1341831\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1341831]\"\n                                value=\"Alimentos picantes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos picantes\"\n                            >\n                    Alimentos picantes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1326130\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos doces\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1326130\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1326130]\"\n                                value=\"Alimentos doces\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos doces\"\n                            >\n                    Alimentos doces                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1338768\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos salgados\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1338768\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1338768]\"\n                                value=\"Alimentos salgados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos salgados\"\n                            >\n                    Alimentos salgados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1694852\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos amargos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1694852\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1694852]\"\n                                value=\"Alimentos amargos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos amargos\"\n                            >\n                    Alimentos amargos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1335845\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos azedos\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1335845\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1335845]\"\n                                value=\"Alimentos azedos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Alimentos azedos\"\n                            >\n                    Alimentos azedos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1431473\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Carne\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1431473\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1431473]\"\n                                value=\"Carne\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Carne\"\n                            >\n                    Carne                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1160881\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Peixe\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1160881\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1160881]\"\n                                value=\"Peixe\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Peixe\"\n                            >\n                    Peixe                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1184307\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Ostra\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1184307\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1184307]\"\n                                value=\"Ostra\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Ostra\"\n                            >\n                    Ostra                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1365150\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Ovo\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1365150\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1365150]\"\n                                value=\"Ovo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Ovo\"\n                            >\n                    Ovo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1851586\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Lim\u00e3o\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1851586\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1851586]\"\n                                value=\"Lim\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Lim\u00e3o\"\n                            >\n                    Lim\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1174580\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Frutas\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1174580\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1174580]\"\n                                value=\"Frutas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Frutas\"\n                            >\n                    Frutas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1695553\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Batata\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1695553\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1695553]\"\n                                value=\"Batata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Batata\"\n                            >\n                    Batata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1098491\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Vegetais\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1098491\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1098491]\"\n                                value=\"Vegetais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Vegetais\"\n                            >\n                    Vegetais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1995017\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Picles\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1995017\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1995017]\"\n                                value=\"Picles\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Picles\"\n                            >\n                    Picles                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1154120\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Pipoca\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1154120\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1154120]\"\n                                value=\"Pipoca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Pipoca\"\n                            >\n                    Pipoca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1698403\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"P\u00e3o\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1698403\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1698403]\"\n                                value=\"P\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"P\u00e3o\"\n                            >\n                    P\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1643227\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Pastel\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1643227\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1643227]\"\n                                value=\"Pastel\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Pastel\"\n                            >\n                    Pastel                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1737892\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Queijo\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1737892\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1737892]\"\n                                value=\"Queijo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Queijo\"\n                            >\n                    Queijo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1346776\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Manteiga\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1346776\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1346776]\"\n                                value=\"Manteiga\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Manteiga\"\n                            >\n                    Manteiga                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1271121\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Sorvete\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1271121\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1271121]\"\n                                value=\"Sorvete\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Sorvete\"\n                            >\n                    Sorvete                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1836866\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Chocolate\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1836866\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1836866]\"\n                                value=\"Chocolate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Chocolate\"\n                            >\n                    Chocolate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1554586\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Leite\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1554586\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1554586]\"\n                                value=\"Leite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Leite\"\n                            >\n                    Leite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1418998\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Ch\u00e1\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1418998\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1418998]\"\n                                value=\"Ch\u00e1\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Ch\u00e1\"\n                            >\n                    Ch\u00e1                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1140161\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Cerveja\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1140161\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1140161]\"\n                                value=\"Cerveja\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Cerveja\"\n                            >\n                    Cerveja                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt2032920\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Vinho\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt2032920\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt2032920]\"\n                                value=\"Vinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Vinho\"\n                            >\n                    Vinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt1999316\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Bebidas destiladas\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt1999316\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt1999316]\"\n                                value=\"Bebidas destiladas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Bebidas destiladas\"\n                            >\n                    Bebidas destiladas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5437915_2_opt2005536\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5437915_2\" data-parsley-multiple=\"fld_5437915_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5437915\"\n                                id=\"fld_5437915_2_opt2005536\"\n                                class=\"fld_5437915_2 option-required\"\n                                name=\"fld_5437915[opt2005536]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5437915_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_8312371_2\" data-field-id=\"fld_8312371_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2165263\" class=\"form-group\" id=\"fld_2165263_2-wrap\">\r\n\t<label id=\"fld_2165263Label\" for=\"fld_2165263_2\" class=\"control-label\">Possui algum transtorno alimentar com: <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1079775\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1079775\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1079775]\"\n                                value=\"Alimentos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Alimentos\"\n                            >\n                    Alimentos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1351504\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Carne de gado\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1351504\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1351504]\"\n                                value=\"Carne de gado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Carne de gado\"\n                            >\n                    Carne de gado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1852419\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Carne de porco\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1852419\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1852419]\"\n                                value=\"Carne de porco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Carne de porco\"\n                            >\n                    Carne de porco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1186436\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Aves\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1186436\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1186436]\"\n                                value=\"Aves\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Aves\"\n                            >\n                    Aves                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1501071\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Peixes\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1501071\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1501071]\"\n                                value=\"Peixes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Peixes\"\n                            >\n                    Peixes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1719938\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Marisco\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1719938\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1719938]\"\n                                value=\"Marisco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Marisco\"\n                            >\n                    Marisco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1229162\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"\u00c1gua\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1229162\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1229162]\"\n                                value=\"\u00c1gua\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"\u00c1gua\"\n                            >\n                    \u00c1gua                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt2073242\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Sopa\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt2073242\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt2073242]\"\n                                value=\"Sopa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Sopa\"\n                            >\n                    Sopa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1593151\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Leite\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1593151\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1593151]\"\n                                value=\"Leite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Leite\"\n                            >\n                    Leite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1588801\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"P\u00e3o\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1588801\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1588801]\"\n                                value=\"P\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"P\u00e3o\"\n                            >\n                    P\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1458687\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Ovo\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1458687\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1458687]\"\n                                value=\"Ovo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Ovo\"\n                            >\n                    Ovo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt2064604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Picles\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt2064604\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt2064604]\"\n                                value=\"Picles\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Picles\"\n                            >\n                    Picles                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1527337\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Feij\u00e3o\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1527337\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1527337]\"\n                                value=\"Feij\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Feij\u00e3o\"\n                            >\n                    Feij\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1838213\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Cebola\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1838213\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1838213]\"\n                                value=\"Cebola\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Cebola\"\n                            >\n                    Cebola                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1855152\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Repolho\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1855152\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1855152]\"\n                                value=\"Repolho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Repolho\"\n                            >\n                    Repolho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1701963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Batata\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1701963\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1701963]\"\n                                value=\"Batata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Batata\"\n                            >\n                    Batata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1641802\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Tomate\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1641802\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1641802]\"\n                                value=\"Tomate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Tomate\"\n                            >\n                    Tomate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1831533\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Vegetais\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1831533\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1831533]\"\n                                value=\"Vegetais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Vegetais\"\n                            >\n                    Vegetais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1882780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Sorvete\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1882780\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1882780]\"\n                                value=\"Sorvete\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Sorvete\"\n                            >\n                    Sorvete                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1117488\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos frios\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1117488\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1117488]\"\n                                value=\"Alimentos frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Alimentos frios\"\n                            >\n                    Alimentos frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1934126\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos quentes\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1934126\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1934126]\"\n                                value=\"Alimentos quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Alimentos quentes\"\n                            >\n                    Alimentos quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1203929\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Alimentos azedos\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1203929\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1203929]\"\n                                value=\"Alimentos azedos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Alimentos azedos\"\n                            >\n                    Alimentos azedos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1597126\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1597126\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1597126]\"\n                                value=\"N\u00e3o possuo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"N\u00e3o possuo\"\n                            >\n                    N\u00e3o possuo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2165263_2_opt1822053\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2165263_2\" data-parsley-multiple=\"fld_2165263_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_2165263\"\n                                id=\"fld_2165263_2_opt1822053\"\n                                class=\"fld_2165263_2 option-required\"\n                                name=\"fld_2165263[opt1822053]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2165263_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_804883_2\" data-field-id=\"fld_804883_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-23\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_3091293\" class=\"form-group\" id=\"fld_3091293_2-wrap\">\r\n\t<label id=\"fld_3091293Label\" for=\"fld_3091293_2\" class=\"control-label\">Que tipo de sede voc\u00ea tem? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt2070868\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Pequenas quantidades\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt2070868\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt2070868]\"\n                                value=\"Pequenas quantidades\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Pequenas quantidades\"\n                            >\n                    Pequenas quantidades                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt1926880\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Grandes quantidades\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt1926880\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt1926880]\"\n                                value=\"Grandes quantidades\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Grandes quantidades\"\n                            >\n                    Grandes quantidades                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt1824128\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Bebidas frias\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt1824128\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt1824128]\"\n                                value=\"Bebidas frias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Bebidas frias\"\n                            >\n                    Bebidas frias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt1903840\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Bebidas quentes\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt1903840\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt1903840]\"\n                                value=\"Bebidas quentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Bebidas quentes\"\n                            >\n                    Bebidas quentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt1924478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Bebidas \u00e0 temperatura ambiente\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt1924478\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt1924478]\"\n                                value=\"Bebidas \u00e0 temperatura ambiente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Bebidas \u00e0 temperatura ambiente\"\n                            >\n                    Bebidas \u00e0 temperatura ambiente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt2023377\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Gelo ou \u00e1gua gelada\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt2023377\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt2023377]\"\n                                value=\"Gelo ou \u00e1gua gelada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Gelo ou \u00e1gua gelada\"\n                            >\n                    Gelo ou \u00e1gua gelada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3091293_2_opt1688907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3091293_2\" data-parsley-multiple=\"fld_3091293_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3091293\"\n                                id=\"fld_3091293_2_opt1688907\"\n                                class=\"fld_3091293_2 option-required\"\n                                name=\"fld_3091293[opt1688907]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3091293_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_821839_2\" data-field-id=\"fld_821839_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-24\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_278843\" class=\"form-group\" id=\"fld_278843_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_278843\" id=\"fld_278843_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_278843\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_278843\" id=\"fld_278843_2_btn\" value=\"\" data-field=\"fld_278843\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_744392\" class=\"form-group\" id=\"fld_744392_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_744392\" id=\"fld_744392_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_744392\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_744392\" id=\"fld_744392_2_btn\" value=\"\" data-field=\"fld_744392\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_962626\" class=\"form-group\" id=\"fld_962626_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_962626\" id=\"fld_962626_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_962626\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_962626\" id=\"fld_962626_2_btn\" value=\"\" data-field=\"fld_962626\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_6\" data-formpage=\"6\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_6\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-25\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8644297\" class=\"form-group\" id=\"fld_8644297_2-wrap\">\r\n\t<label id=\"fld_8644297Label\" for=\"fld_8644297_2\" class=\"control-label\">Voc\u00ea ou algum familiar \u00e9 portador de HIV\/AIDS? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1402298\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1487186\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1659832\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1702867\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1192255\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1407122\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt2029916\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1533618\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8644297_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8644297_2\" data-parsley-multiple=\"fld_8644297_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_8644297\"\n                                id=\"fld_8644297_2_opt1180673\"\n                                class=\"fld_8644297_2 option-required\"\n                                name=\"fld_8644297[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8644297_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1535034\" class=\"form-group\" id=\"fld_1535034_2-wrap\">\r\n\t<label id=\"fld_1535034Label\" for=\"fld_1535034_2\" class=\"control-label\">Voc\u00ea ou algum familiar tem depend\u00eancia de \u00e1lcool? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1402298\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1487186\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1659832\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1702867\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1192255\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1407122\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt2029916\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1533618\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1535034_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1535034_2\" data-parsley-multiple=\"fld_1535034_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_1535034\"\n                                id=\"fld_1535034_2_opt1180673\"\n                                class=\"fld_1535034_2 option-required\"\n                                name=\"fld_1535034[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1535034_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-26\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_739625\" class=\"form-group\" id=\"fld_739625_2-wrap\">\r\n\t<label id=\"fld_739625Label\" for=\"fld_739625_2\" class=\"control-label\">Voc\u00ea ou algum familiar possui alergia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1402298\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1487186\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1659832\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1702867\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1192255\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1407122\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt2029916\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1533618\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_739625_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_739625_2\" data-parsley-multiple=\"fld_739625_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_739625\"\n                                id=\"fld_739625_2_opt1180673\"\n                                class=\"fld_739625_2 option-required\"\n                                name=\"fld_739625[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_739625_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_7819773\" class=\"form-group\" id=\"fld_7819773_2-wrap\">\r\n\t<label id=\"fld_7819773Label\" for=\"fld_7819773_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de alzheimer? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1402298\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1487186\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1659832\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1702867\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1192255\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1407122\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt2029916\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1533618\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7819773_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7819773_2\" data-parsley-multiple=\"fld_7819773_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_7819773\"\n                                id=\"fld_7819773_2_opt1180673\"\n                                class=\"fld_7819773_2 option-required\"\n                                name=\"fld_7819773[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7819773_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-27\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7124119\" class=\"form-group\" id=\"fld_7124119_2-wrap\">\r\n\t<label id=\"fld_7124119Label\" for=\"fld_7124119_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de anemia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1402298\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1487186\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1659832\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1702867\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1192255\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1407122\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt2029916\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1533618\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7124119_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7124119_2\" data-parsley-multiple=\"fld_7124119_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_7124119\"\n                                id=\"fld_7124119_2_opt1180673\"\n                                class=\"fld_7124119_2 option-required\"\n                                name=\"fld_7124119[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7124119_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5003379\" class=\"form-group\" id=\"fld_5003379_2-wrap\">\r\n\t<label id=\"fld_5003379Label\" for=\"fld_5003379_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de anemia falciforme? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1402298\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1487186\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1659832\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1702867\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1192255\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1407122\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt2029916\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1533618\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5003379_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5003379_2\" data-parsley-multiple=\"fld_5003379_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5003379\"\n                                id=\"fld_5003379_2_opt1180673\"\n                                class=\"fld_5003379_2 option-required\"\n                                name=\"fld_5003379[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5003379_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-28\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4726702\" class=\"form-group\" id=\"fld_4726702_2-wrap\">\r\n\t<label id=\"fld_4726702Label\" for=\"fld_4726702_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de artrite? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1402298\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1487186\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1659832\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1702867\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1192255\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1407122\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt2029916\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1533618\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4726702_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4726702_2\" data-parsley-multiple=\"fld_4726702_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4726702\"\n                                id=\"fld_4726702_2_opt1180673\"\n                                class=\"fld_4726702_2 option-required\"\n                                name=\"fld_4726702[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4726702_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2372214\" class=\"form-group\" id=\"fld_2372214_2-wrap\">\r\n\t<label id=\"fld_2372214Label\" for=\"fld_2372214_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de asma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1402298\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1487186\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1659832\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1702867\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1192255\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1407122\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt2029916\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1533618\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2372214_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2372214_2\" data-parsley-multiple=\"fld_2372214_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2372214\"\n                                id=\"fld_2372214_2_opt1180673\"\n                                class=\"fld_2372214_2 option-required\"\n                                name=\"fld_2372214[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2372214_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-29\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_9253278\" class=\"form-group\" id=\"fld_9253278_2-wrap\">\r\n\t<label id=\"fld_9253278Label\" for=\"fld_9253278_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de defeitos de nascen\u00e7a? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1402298\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1487186\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1659832\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1702867\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1192255\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1407122\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt2029916\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1533618\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9253278_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9253278_2\" data-parsley-multiple=\"fld_9253278_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_9253278\"\n                                id=\"fld_9253278_2_opt1180673\"\n                                class=\"fld_9253278_2 option-required\"\n                                name=\"fld_9253278[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9253278_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2941180\" class=\"form-group\" id=\"fld_2941180_2-wrap\">\r\n\t<label id=\"fld_2941180Label\" for=\"fld_2941180_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de dist\u00farbio hemorr\u00e1gico? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1402298\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1487186\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1659832\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1702867\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1192255\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1407122\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt2029916\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1533618\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2941180_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2941180_2\" data-parsley-multiple=\"fld_2941180_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2941180\"\n                                id=\"fld_2941180_2_opt1180673\"\n                                class=\"fld_2941180_2 option-required\"\n                                name=\"fld_2941180[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2941180_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-30\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2987199\" class=\"form-group\" id=\"fld_2987199_2-wrap\">\r\n\t<label id=\"fld_2987199Label\" for=\"fld_2987199_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1402298\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1487186\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1659832\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1702867\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1192255\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1407122\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt2029916\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1533618\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2987199_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2987199_2\" data-parsley-multiple=\"fld_2987199_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2987199\"\n                                id=\"fld_2987199_2_opt1180673\"\n                                class=\"fld_2987199_2 option-required\"\n                                name=\"fld_2987199[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2987199_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5834546\" class=\"form-group\" id=\"fld_5834546_2-wrap\">\r\n\t<label id=\"fld_5834546Label\" for=\"fld_5834546_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer de mama? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1402298\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1487186\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1659832\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1702867\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1192255\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1407122\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt2029916\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1533618\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5834546_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5834546_2\" data-parsley-multiple=\"fld_5834546_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5834546\"\n                                id=\"fld_5834546_2_opt1180673\"\n                                class=\"fld_5834546_2 option-required\"\n                                name=\"fld_5834546[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5834546_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-31\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2091625\" class=\"form-group\" id=\"fld_2091625_2-wrap\">\r\n\t<label id=\"fld_2091625Label\" for=\"fld_2091625_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de c\u00e2ncer de pr\u00f3stata? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1402298\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1487186\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1659832\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1702867\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1192255\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1407122\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt2029916\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1533618\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2091625_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2091625_2\" data-parsley-multiple=\"fld_2091625_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2091625\"\n                                id=\"fld_2091625_2_opt1180673\"\n                                class=\"fld_2091625_2 option-required\"\n                                name=\"fld_2091625[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2091625_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2327864\" class=\"form-group\" id=\"fld_2327864_2-wrap\">\r\n\t<label id=\"fld_2327864Label\" for=\"fld_2327864_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de depress\u00e3o? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1402298\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1487186\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1659832\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1702867\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1192255\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1407122\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt2029916\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1533618\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2327864_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2327864_2\" data-parsley-multiple=\"fld_2327864_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2327864\"\n                                id=\"fld_2327864_2_opt1180673\"\n                                class=\"fld_2327864_2 option-required\"\n                                name=\"fld_2327864[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2327864_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-32\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_4341577\" class=\"form-group\" id=\"fld_4341577_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_4341577\" id=\"fld_4341577_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_4341577\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_4341577\" id=\"fld_4341577_2_btn\" value=\"\" data-field=\"fld_4341577\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3822246\" class=\"form-group\" id=\"fld_3822246_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_3822246\" id=\"fld_3822246_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_3822246\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_3822246\" id=\"fld_3822246_2_btn\" value=\"\" data-field=\"fld_3822246\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_7588033\" class=\"form-group\" id=\"fld_7588033_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_7588033\" id=\"fld_7588033_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_7588033\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_7588033\" id=\"fld_7588033_2_btn\" value=\"\" data-field=\"fld_7588033\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_7\" data-formpage=\"7\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_7\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-33\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6756990\" class=\"form-group\" id=\"fld_6756990_2-wrap\">\r\n\t<label id=\"fld_6756990Label\" for=\"fld_6756990_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de diabetes? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1402298\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1487186\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1659832\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1702867\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1192255\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1407122\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt2029916\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1533618\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6756990_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6756990_2\" data-parsley-multiple=\"fld_6756990_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6756990\"\n                                id=\"fld_6756990_2_opt1180673\"\n                                class=\"fld_6756990_2 option-required\"\n                                name=\"fld_6756990[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6756990_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2505830\" class=\"form-group\" id=\"fld_2505830_2-wrap\">\r\n\t<label id=\"fld_2505830Label\" for=\"fld_2505830_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de enfisema? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1402298\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1487186\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1659832\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1702867\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1192255\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1407122\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt2029916\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1533618\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2505830_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2505830_2\" data-parsley-multiple=\"fld_2505830_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2505830\"\n                                id=\"fld_2505830_2_opt1180673\"\n                                class=\"fld_2505830_2 option-required\"\n                                name=\"fld_2505830[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2505830_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-34\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2805064\" class=\"form-group\" id=\"fld_2805064_2-wrap\">\r\n\t<label id=\"fld_2805064Label\" for=\"fld_2805064_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de epilepsia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1402298\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1487186\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1659832\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1702867\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1192255\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1407122\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt2029916\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1533618\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2805064_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2805064_2\" data-parsley-multiple=\"fld_2805064_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2805064\"\n                                id=\"fld_2805064_2_opt1180673\"\n                                class=\"fld_2805064_2 option-required\"\n                                name=\"fld_2805064[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2805064_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_4444936\" class=\"form-group\" id=\"fld_4444936_2-wrap\">\r\n\t<label id=\"fld_4444936Label\" for=\"fld_4444936_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de glaucoma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1402298\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1487186\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1659832\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1702867\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1192255\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1407122\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt2029916\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1533618\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4444936_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4444936_2\" data-parsley-multiple=\"fld_4444936_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4444936\"\n                                id=\"fld_4444936_2_opt1180673\"\n                                class=\"fld_4444936_2 option-required\"\n                                name=\"fld_4444936[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4444936_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-35\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4453698\" class=\"form-group\" id=\"fld_4453698_2-wrap\">\r\n\t<label id=\"fld_4453698Label\" for=\"fld_4453698_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de problemas card\u00edacos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1402298\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1487186\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1659832\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1702867\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1192255\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1407122\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt2029916\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1533618\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4453698_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4453698_2\" data-parsley-multiple=\"fld_4453698_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4453698\"\n                                id=\"fld_4453698_2_opt1180673\"\n                                class=\"fld_4453698_2 option-required\"\n                                name=\"fld_4453698[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4453698_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1629592\" class=\"form-group\" id=\"fld_1629592_2-wrap\">\r\n\t<label id=\"fld_1629592Label\" for=\"fld_1629592_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu ataque card\u00edaco? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1402298\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1487186\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1659832\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1702867\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1192255\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1407122\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt2029916\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1533618\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1629592_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1629592_2\" data-parsley-multiple=\"fld_1629592_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_1629592\"\n                                id=\"fld_1629592_2_opt1180673\"\n                                class=\"fld_1629592_2 option-required\"\n                                name=\"fld_1629592[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1629592_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-36\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5725260\" class=\"form-group\" id=\"fld_5725260_2-wrap\">\r\n\t<label id=\"fld_5725260Label\" for=\"fld_5725260_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de press\u00e3o alta? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1402298\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1487186\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1659832\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1702867\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1192255\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1407122\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt2029916\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1533618\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5725260_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5725260_2\" data-parsley-multiple=\"fld_5725260_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5725260\"\n                                id=\"fld_5725260_2_opt1180673\"\n                                class=\"fld_5725260_2 option-required\"\n                                name=\"fld_5725260[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5725260_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_224243\" class=\"form-group\" id=\"fld_224243_2-wrap\">\r\n\t<label id=\"fld_224243Label\" for=\"fld_224243_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a renal? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1402298\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1487186\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1659832\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1702867\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1192255\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1407122\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt2029916\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1533618\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_224243_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_224243_2\" data-parsley-multiple=\"fld_224243_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_224243\"\n                                id=\"fld_224243_2_opt1180673\"\n                                class=\"fld_224243_2 option-required\"\n                                name=\"fld_224243[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_224243_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-37\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4062738\" class=\"form-group\" id=\"fld_4062738_2-wrap\">\r\n\t<label id=\"fld_4062738Label\" for=\"fld_4062738_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a hep\u00e1tica? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1402298\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1487186\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1659832\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1702867\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1192255\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1407122\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt2029916\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1533618\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4062738_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4062738_2\" data-parsley-multiple=\"fld_4062738_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4062738\"\n                                id=\"fld_4062738_2_opt1180673\"\n                                class=\"fld_4062738_2 option-required\"\n                                name=\"fld_4062738[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4062738_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2448871\" class=\"form-group\" id=\"fld_2448871_2-wrap\">\r\n\t<label id=\"fld_2448871Label\" for=\"fld_2448871_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de enxaquecas ou dores de cabe\u00e7a constantes? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1402298\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1487186\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1659832\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1702867\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1192255\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1407122\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt2029916\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1533618\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2448871_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2448871_2\" data-parsley-multiple=\"fld_2448871_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2448871\"\n                                id=\"fld_2448871_2_opt1180673\"\n                                class=\"fld_2448871_2 option-required\"\n                                name=\"fld_2448871[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2448871_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-38\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_3989334\" class=\"form-group\" id=\"fld_3989334_2-wrap\">\r\n\t<label id=\"fld_3989334Label\" for=\"fld_3989334_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de doen\u00e7a mental? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1402298\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1487186\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1659832\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1702867\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1192255\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1407122\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt2029916\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1533618\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3989334_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3989334_2\" data-parsley-multiple=\"fld_3989334_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_3989334\"\n                                id=\"fld_3989334_2_opt1180673\"\n                                class=\"fld_3989334_2 option-required\"\n                                name=\"fld_3989334[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3989334_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6403231\" class=\"form-group\" id=\"fld_6403231_2-wrap\">\r\n\t<label id=\"fld_6403231Label\" for=\"fld_6403231_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu de pneumonia? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1402298\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1487186\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1659832\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1702867\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1192255\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1407122\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt2029916\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1533618\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6403231_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6403231_2\" data-parsley-multiple=\"fld_6403231_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6403231\"\n                                id=\"fld_6403231_2_opt1180673\"\n                                class=\"fld_6403231_2 option-required\"\n                                name=\"fld_6403231[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6403231_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-39\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4249673\" class=\"form-group\" id=\"fld_4249673_2-wrap\">\r\n\t<label id=\"fld_4249673Label\" for=\"fld_4249673_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de tuberculose? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1402298\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1487186\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1659832\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1702867\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1192255\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1407122\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt2029916\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1533618\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4249673_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4249673_2\" data-parsley-multiple=\"fld_4249673_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_4249673\"\n                                id=\"fld_4249673_2_opt1180673\"\n                                class=\"fld_4249673_2 option-required\"\n                                name=\"fld_4249673[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4249673_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6750828\" class=\"form-group\" id=\"fld_6750828_2-wrap\">\r\n\t<label id=\"fld_6750828Label\" for=\"fld_6750828_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofreu acidente vascular cerebral? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1402298\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1487186\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1659832\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1702867\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1192255\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1407122\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt2029916\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1533618\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6750828_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6750828_2\" data-parsley-multiple=\"fld_6750828_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_6750828\"\n                                id=\"fld_6750828_2_opt1180673\"\n                                class=\"fld_6750828_2 option-required\"\n                                name=\"fld_6750828[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6750828_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-40\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5282480\" class=\"form-group\" id=\"fld_5282480_2-wrap\">\r\n\t<label id=\"fld_5282480Label\" for=\"fld_5282480_2\" class=\"control-label\">Voc\u00ea ou algum familiar sofre de \u00falceras? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1402298\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1487186\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1659832\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1702867\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1192255\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1407122\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt2029916\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1533618\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5282480_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5282480_2\" data-parsley-multiple=\"fld_5282480_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_5282480\"\n                                id=\"fld_5282480_2_opt1180673\"\n                                class=\"fld_5282480_2 option-required\"\n                                name=\"fld_5282480[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5282480_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2861783\" class=\"form-group\" id=\"fld_2861783_2-wrap\">\r\n\t<label id=\"fld_2861783Label\" for=\"fld_2861783_2\" class=\"control-label\">Voc\u00ea ou algum familiar tentou ou praticou suic\u00eddio? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1402298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Voc\u00ea\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1402298\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1402298]\"\n                                value=\"Voc\u00ea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Voc\u00ea\"\n                            >\n                    Voc\u00ea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1487186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Conjugue\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1487186\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1487186]\"\n                                value=\"Conjugue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Conjugue\"\n                            >\n                    Conjugue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1659832\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1659832\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1659832]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1702867\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Irm\u00e3o(\u00e3)\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1702867\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1702867]\"\n                                value=\"Irm\u00e3o(\u00e3)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Irm\u00e3o(\u00e3)\"\n                            >\n                    Irm\u00e3o(\u00e3)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1192255\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3e\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1192255\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1192255]\"\n                                value=\"M\u00e3e\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"M\u00e3e\"\n                            >\n                    M\u00e3e                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1407122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Pai\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1407122\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1407122]\"\n                                value=\"Pai\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Pai\"\n                            >\n                    Pai                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt2029916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Tios(as)\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt2029916\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt2029916]\"\n                                value=\"Tios(as)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Tios(as)\"\n                            >\n                    Tios(as)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1533618\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Av\u00f3s\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1533618\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1533618]\"\n                                value=\"Av\u00f3s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Av\u00f3s\"\n                            >\n                    Av\u00f3s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2861783_2_opt1180673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2861783_2\" data-parsley-multiple=\"fld_2861783_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhum dos listados\"\n                                data-field=\"fld_2861783\"\n                                id=\"fld_2861783_2_opt1180673\"\n                                class=\"fld_2861783_2 option-required\"\n                                name=\"fld_2861783[opt1180673]\"\n                                value=\"Nenhum dos listados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2861783_2\"\n                                                                data-calc-value=\"Nenhum dos listados\"\n                            >\n                    Nenhum dos listados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-41\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_543737\" class=\"form-group\" id=\"fld_543737_2-wrap\">\r\n\t<label id=\"fld_543737Label\" for=\"fld_543737_2\" class=\"control-label\">Alguma outra doen\u00e7a relevante em algum familiar?<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_543737\" value=\"\" data-field=\"fld_543737\" class=\"form-control\" id=\"fld_543737_2\" rows=\"4\"    aria-labelledby=\"fld_543737Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-42\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_2697902\" class=\"form-group\" id=\"fld_2697902_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_2697902\" id=\"fld_2697902_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_2697902\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_2697902\" id=\"fld_2697902_2_btn\" value=\"\" data-field=\"fld_2697902\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_7233284\" class=\"form-group\" id=\"fld_7233284_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_7233284\" id=\"fld_7233284_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_7233284\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_7233284\" id=\"fld_7233284_2_btn\" value=\"\" data-field=\"fld_7233284\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_1805497\" class=\"form-group\" id=\"fld_1805497_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_1805497\" id=\"fld_1805497_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_1805497\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_1805497\" id=\"fld_1805497_2_btn\" value=\"\" data-field=\"fld_1805497\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_8\" data-formpage=\"8\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_8\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-43\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8297592\" class=\"form-group\" id=\"fld_8297592_2-wrap\">\r\n\t<label id=\"fld_8297592Label\" for=\"fld_8297592_2\" class=\"control-label\">Cardiovascular <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1841171\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Press\u00e3o arterial alta\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1841171\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1841171]\"\n                                value=\"Press\u00e3o arterial alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Press\u00e3o arterial alta\"\n                            >\n                    Press\u00e3o arterial alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1058545\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Press\u00e3o arterial baixa\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1058545\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1058545]\"\n                                value=\"Press\u00e3o arterial baixa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Press\u00e3o arterial baixa\"\n                            >\n                    Press\u00e3o arterial baixa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt2060889\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Dor no t\u00f3rax do lado esquerdo\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt2060889\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt2060889]\"\n                                value=\"Dor no t\u00f3rax do lado esquerdo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Dor no t\u00f3rax do lado esquerdo\"\n                            >\n                    Dor no t\u00f3rax do lado esquerdo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1328748\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e1 circula\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1328748\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1328748]\"\n                                value=\"M\u00e1 circula\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"M\u00e1 circula\u00e7\u00e3o\"\n                            >\n                    M\u00e1 circula\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt2018373\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt2018373\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt2018373]\"\n                                value=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es\"\n                            >\n                    Incha\u00e7o nos tornozelos ou articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1390552\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Palpita\u00e7\u00f5es cardiacas\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1390552\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1390552]\"\n                                value=\"Palpita\u00e7\u00f5es cardiacas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Palpita\u00e7\u00f5es cardiacas\"\n                            >\n                    Palpita\u00e7\u00f5es cardiacas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1143912\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1143912\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1143912]\"\n                                value=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Constri\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                            >\n                    Constri\u00e7\u00e3o do cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1336817\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1336817\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1336817]\"\n                                value=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Dilata\u00e7\u00e3o do cora\u00e7\u00e3o\"\n                            >\n                    Dilata\u00e7\u00e3o do cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1637625\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Palpita\u00e7\u00f5es cardiacas\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1637625\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1637625]\"\n                                value=\"Palpita\u00e7\u00f5es cardiacas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Palpita\u00e7\u00f5es cardiacas\"\n                            >\n                    Palpita\u00e7\u00f5es cardiacas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1183665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1183665\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1183665]\"\n                                value=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o\"\n                            >\n                    Sensa\u00e7\u00e3o de vibra\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1388785\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Acidente vascular cerebral\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1388785\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1388785]\"\n                                value=\"Acidente vascular cerebral\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Acidente vascular cerebral\"\n                            >\n                    Acidente vascular cerebral                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1063189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00e3os e\/ou p\u00e9s frios\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1063189\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1063189]\"\n                                value=\"M\u00e3os e\/ou p\u00e9s frios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"M\u00e3os e\/ou p\u00e9s frios\"\n                            >\n                    M\u00e3os e\/ou p\u00e9s frios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1347171\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Colesterol elevado\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1347171\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1347171]\"\n                                value=\"Colesterol elevado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Colesterol elevado\"\n                            >\n                    Colesterol elevado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1225900\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Colesterol bom baixo (HDL)\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1225900\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1225900]\"\n                                value=\"Colesterol bom baixo (HDL)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Colesterol bom baixo (HDL)\"\n                            >\n                    Colesterol bom baixo (HDL)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1883518\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Co\u00e1gulos sangu\u00edneos\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1883518\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1883518]\"\n                                value=\"Co\u00e1gulos sangu\u00edneos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Co\u00e1gulos sangu\u00edneos\"\n                            >\n                    Co\u00e1gulos sangu\u00edneos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1642685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1642685\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1642685]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8297592_2_opt1542870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8297592_2\" data-parsley-multiple=\"fld_8297592_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8297592\"\n                                id=\"fld_8297592_2_opt1542870\"\n                                class=\"fld_8297592_2 option-required\"\n                                name=\"fld_8297592[opt1542870]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8297592_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3571860_2\" data-field-id=\"fld_3571860_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_8430632\" class=\"form-group\" id=\"fld_8430632_2-wrap\">\r\n\t<label id=\"fld_8430632Label\" for=\"fld_8430632_2\" class=\"control-label\">Respirat\u00f3rio <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1600203\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o irregular\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1600203\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1600203]\"\n                                value=\"Respira\u00e7\u00e3o irregular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o irregular\"\n                            >\n                    Respira\u00e7\u00e3o irregular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1128382\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o lenta\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1128382\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1128382]\"\n                                value=\"Respira\u00e7\u00e3o lenta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o lenta\"\n                            >\n                    Respira\u00e7\u00e3o lenta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1727204\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o acelerada\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1727204\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1727204]\"\n                                value=\"Respira\u00e7\u00e3o acelerada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o acelerada\"\n                            >\n                    Respira\u00e7\u00e3o acelerada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1132491\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o profunda\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1132491\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1132491]\"\n                                value=\"Respira\u00e7\u00e3o profunda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o profunda\"\n                            >\n                    Respira\u00e7\u00e3o profunda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1066158\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1066158\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1066158]\"\n                                value=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o obstru\u00edda\"\n                            >\n                    Respira\u00e7\u00e3o obstru\u00edda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1222215\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o fraca\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1222215\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1222215]\"\n                                value=\"Respira\u00e7\u00e3o fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o fraca\"\n                            >\n                    Respira\u00e7\u00e3o fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1532189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Respira\u00e7\u00e3o com chiado\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1532189\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1532189]\"\n                                value=\"Respira\u00e7\u00e3o com chiado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Respira\u00e7\u00e3o com chiado\"\n                            >\n                    Respira\u00e7\u00e3o com chiado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1096865\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Chocalhar no peito\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1096865\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1096865]\"\n                                value=\"Chocalhar no peito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Chocalhar no peito\"\n                            >\n                    Chocalhar no peito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1990444\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade respirat\u00f3ria\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1990444\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1990444]\"\n                                value=\"Dificuldade respirat\u00f3ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Dificuldade respirat\u00f3ria\"\n                            >\n                    Dificuldade respirat\u00f3ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1980315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Falta de ar\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1980315\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1980315]\"\n                                value=\"Falta de ar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Falta de ar\"\n                            >\n                    Falta de ar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1091923\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Enfisema pulmonar\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1091923\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1091923]\"\n                                value=\"Enfisema pulmonar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Enfisema pulmonar\"\n                            >\n                    Enfisema pulmonar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1084059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Asfixia\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1084059\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1084059]\"\n                                value=\"Asfixia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Asfixia\"\n                            >\n                    Asfixia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1817760\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Tosse persistente\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1817760\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1817760]\"\n                                value=\"Tosse persistente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Tosse persistente\"\n                            >\n                    Tosse persistente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1178422\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Alergia a p\u00f3\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1178422\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1178422]\"\n                                value=\"Alergia a p\u00f3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Alergia a p\u00f3\"\n                            >\n                    Alergia a p\u00f3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1962993\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Ataques de asma\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1962993\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1962993]\"\n                                value=\"Ataques de asma\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Ataques de asma\"\n                            >\n                    Ataques de asma                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt2090341\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Secre\u00e7\u00e3o nasal\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt2090341\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt2090341]\"\n                                value=\"Secre\u00e7\u00e3o nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Secre\u00e7\u00e3o nasal\"\n                            >\n                    Secre\u00e7\u00e3o nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1230451\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Congest\u00e3o nasal\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1230451\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1230451]\"\n                                value=\"Congest\u00e3o nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Congest\u00e3o nasal\"\n                            >\n                    Congest\u00e3o nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1631590\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Sinusite\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1631590\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1631590]\"\n                                value=\"Sinusite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Sinusite\"\n                            >\n                    Sinusite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1256125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1256125\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1256125]\"\n                                value=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Infec\u00e7\u00f5es respirat\u00f3rias frequentes\"\n                            >\n                    Infec\u00e7\u00f5es respirat\u00f3rias frequentes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1310217\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Dor de garganta\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1310217\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1310217]\"\n                                value=\"Dor de garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Dor de garganta\"\n                            >\n                    Dor de garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1352673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Gripe\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1352673\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1352673]\"\n                                value=\"Gripe\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Gripe\"\n                            >\n                    Gripe                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1308142\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Escarro amarelo\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1308142\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1308142]\"\n                                value=\"Escarro amarelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Escarro amarelo\"\n                            >\n                    Escarro amarelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1198987\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Escarro verde\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1198987\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1198987]\"\n                                value=\"Escarro verde\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Escarro verde\"\n                            >\n                    Escarro verde                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1193701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Escarro preto\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1193701\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1193701]\"\n                                value=\"Escarro preto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Escarro preto\"\n                            >\n                    Escarro preto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt1867149\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Escarro com sangue\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt1867149\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt1867149]\"\n                                value=\"Escarro com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Escarro com sangue\"\n                            >\n                    Escarro com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt2003271\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt2003271\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt2003271]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8430632_2_opt2012644\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8430632_2\" data-parsley-multiple=\"fld_8430632_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8430632\"\n                                id=\"fld_8430632_2_opt2012644\"\n                                class=\"fld_8430632_2 option-required\"\n                                name=\"fld_8430632[opt2012644]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8430632_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6470066_2\" data-field-id=\"fld_6470066_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-44\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5600968\" class=\"form-group\" id=\"fld_5600968_2-wrap\">\r\n\t<label id=\"fld_5600968Label\" for=\"fld_5600968_2\" class=\"control-label\">Gastrointestinal <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1130273\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Arroto\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1130273\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1130273]\"\n                                value=\"Arroto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Arroto\"\n                            >\n                    Arroto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1214617\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Mau h\u00e1lito\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1214617\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1214617]\"\n                                value=\"Mau h\u00e1lito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Mau h\u00e1lito\"\n                            >\n                    Mau h\u00e1lito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1490099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Azia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1490099\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1490099]\"\n                                value=\"Azia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Azia\"\n                            >\n                    Azia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1958302\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1usea\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1958302\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1958302]\"\n                                value=\"N\u00e1usea\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"N\u00e1usea\"\n                            >\n                    N\u00e1usea                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1268630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Indigest\u00e3o\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1268630\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1268630]\"\n                                value=\"Indigest\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Indigest\u00e3o\"\n                            >\n                    Indigest\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1115122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Plenitude\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1115122\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1115122]\"\n                                value=\"Plenitude\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Plenitude\"\n                            >\n                    Plenitude                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1856349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1856349\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1856349]\"\n                                value=\"Incha\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Incha\u00e7o\"\n                            >\n                    Incha\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1359453\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1359453\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1359453]\"\n                                value=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de vazio no est\u00f4mago\"\n                            >\n                    Sensa\u00e7\u00e3o de vazio no est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1352789\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Peso no est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1352789\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1352789]\"\n                                value=\"Peso no est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Peso no est\u00f4mago\"\n                            >\n                    Peso no est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1508596\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"V\u00f4mitos\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1508596\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1508596]\"\n                                value=\"V\u00f4mitos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"V\u00f4mitos\"\n                            >\n                    V\u00f4mitos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1633924\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Dor abdominal\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1633924\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1633924]\"\n                                value=\"Dor abdominal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Dor abdominal\"\n                            >\n                    Dor abdominal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1558725\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Dor de est\u00f4mago\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1558725\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1558725]\"\n                                value=\"Dor de est\u00f4mago\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Dor de est\u00f4mago\"\n                            >\n                    Dor de est\u00f4mago                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1388446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"H\u00e9rnia de hiato\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1388446\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1388446]\"\n                                value=\"H\u00e9rnia de hiato\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"H\u00e9rnia de hiato\"\n                            >\n                    H\u00e9rnia de hiato                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1353067\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"\u00dalceras estomacais\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1353067\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1353067]\"\n                                value=\"\u00dalceras estomacais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"\u00dalceras estomacais\"\n                            >\n                    \u00dalceras estomacais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1616061\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Problemas de f\u00edgado\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1616061\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1616061]\"\n                                value=\"Problemas de f\u00edgado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Problemas de f\u00edgado\"\n                            >\n                    Problemas de f\u00edgado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1575663\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Hepatite\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1575663\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1575663]\"\n                                value=\"Hepatite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Hepatite\"\n                            >\n                    Hepatite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1978855\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"C\u00e1lculo ou barro biliar\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1978855\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1978855]\"\n                                value=\"C\u00e1lculo ou barro biliar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"C\u00e1lculo ou barro biliar\"\n                            >\n                    C\u00e1lculo ou barro biliar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1700759\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Gases\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1700759\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1700759]\"\n                                value=\"Gases\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Gases\"\n                            >\n                    Gases                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1053833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Flatul\u00eancia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1053833\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1053833]\"\n                                value=\"Flatul\u00eancia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Flatul\u00eancia\"\n                            >\n                    Flatul\u00eancia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1980669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"C\u00f3licas intestinais\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1980669\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1980669]\"\n                                value=\"C\u00f3licas intestinais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"C\u00f3licas intestinais\"\n                            >\n                    C\u00f3licas intestinais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1425904\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Colite\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1425904\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1425904]\"\n                                value=\"Colite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Colite\"\n                            >\n                    Colite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt2067315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Pris\u00e3o de ventre\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt2067315\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt2067315]\"\n                                value=\"Pris\u00e3o de ventre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Pris\u00e3o de ventre\"\n                            >\n                    Pris\u00e3o de ventre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1654550\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1654550\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1654550]\"\n                                value=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"1 \u00e0 2 evacua\u00e7\u00f5es por dia\"\n                            >\n                    1 \u00e0 2 evacua\u00e7\u00f5es por dia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1673059\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1673059\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1673059]\"\n                                value=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"2 ou menos evacua\u00e7\u00f5es por semana\"\n                            >\n                    2 ou menos evacua\u00e7\u00f5es por semana                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1404606\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Dor retal\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1404606\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1404606]\"\n                                value=\"Dor retal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Dor retal\"\n                            >\n                    Dor retal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1711979\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Hemorr\u00f3idas\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1711979\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1711979]\"\n                                value=\"Hemorr\u00f3idas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Hemorr\u00f3idas\"\n                            >\n                    Hemorr\u00f3idas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1625351\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Caibras\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1625351\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1625351]\"\n                                value=\"Caibras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Caibras\"\n                            >\n                    Caibras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1158478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Anorexia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1158478\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1158478]\"\n                                value=\"Anorexia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Anorexia\"\n                            >\n                    Anorexia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1095824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Bulimia\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1095824\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1095824]\"\n                                value=\"Bulimia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Bulimia\"\n                            >\n                    Bulimia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt2011413\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt2011413\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt2011413]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5600968_2_opt1165916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5600968_2\" data-parsley-multiple=\"fld_5600968_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5600968\"\n                                id=\"fld_5600968_2_opt1165916\"\n                                class=\"fld_5600968_2 option-required\"\n                                name=\"fld_5600968[opt1165916]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5600968_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2917925_2\" data-field-id=\"fld_2917925_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2481233\" class=\"form-group\" id=\"fld_2481233_2-wrap\">\r\n\t<label id=\"fld_2481233Label\" for=\"fld_2481233_2\" class=\"control-label\">Fezes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1474365\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Aguada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1474365\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1474365]\"\n                                value=\"Aguada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Aguada\"\n                            >\n                    Aguada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1237091\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Biliosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1237091\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1237091]\"\n                                value=\"Biliosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Biliosa\"\n                            >\n                    Biliosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1823293\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Diarreica\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1823293\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1823293]\"\n                                value=\"Diarreica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Diarreica\"\n                            >\n                    Diarreica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1462446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Mole\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1462446\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1462446]\"\n                                value=\"Mole\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Mole\"\n                            >\n                    Mole                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1568393\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Seca\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1568393\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1568393]\"\n                                value=\"Seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Seca\"\n                            >\n                    Seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1214726\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Solta\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1214726\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1214726]\"\n                                value=\"Solta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Solta\"\n                            >\n                    Solta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1941003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Volumosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1941003\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1941003]\"\n                                value=\"Volumosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Volumosa\"\n                            >\n                    Volumosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1683204\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Espumosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1683204\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1683204]\"\n                                value=\"Espumosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Espumosa\"\n                            >\n                    Espumosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1906127\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Gordurosa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1906127\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1906127]\"\n                                value=\"Gordurosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Gordurosa\"\n                            >\n                    Gordurosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1120921\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Inodora\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1120921\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1120921]\"\n                                value=\"Inodora\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Inodora\"\n                            >\n                    Inodora                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1161657\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"F\u00e9tida\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1161657\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1161657]\"\n                                value=\"F\u00e9tida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"F\u00e9tida\"\n                            >\n                    F\u00e9tida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1921606\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Viscosa ou com muco\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1921606\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1921606]\"\n                                value=\"Viscosa ou com muco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Viscosa ou com muco\"\n                            >\n                    Viscosa ou com muco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1085211\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Sanguinolenta ou com sangue\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1085211\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1085211]\"\n                                value=\"Sanguinolenta ou com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Sanguinolenta ou com sangue\"\n                            >\n                    Sanguinolenta ou com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1805023\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Involunt\u00e1ria\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1805023\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1805023]\"\n                                value=\"Involunt\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Involunt\u00e1ria\"\n                            >\n                    Involunt\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1102273\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Frequente\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1102273\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1102273]\"\n                                value=\"Frequente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Frequente\"\n                            >\n                    Frequente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1055771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Regular\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1055771\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1055771]\"\n                                value=\"Regular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Regular\"\n                            >\n                    Regular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1974156\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Escassa\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1974156\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1974156]\"\n                                value=\"Escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Escassa\"\n                            >\n                    Escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1192795\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Dif\u00edcil \"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1192795\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1192795]\"\n                                value=\"Dif\u00edcil \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Dif\u00edcil \"\n                            >\n                    Dif\u00edcil                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1488604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Constipada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1488604\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1488604]\"\n                                value=\"Constipada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Constipada\"\n                            >\n                    Constipada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1467778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1467778\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1467778]\"\n                                value=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"C\u00f3lica antes da evacua\u00e7\u00e3o \"\n                            >\n                    C\u00f3lica antes da evacua\u00e7\u00e3o                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1280283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Dolorosa ao sair\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1280283\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1280283]\"\n                                value=\"Dolorosa ao sair\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Dolorosa ao sair\"\n                            >\n                    Dolorosa ao sair                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1783669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1783669\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1783669]\"\n                                value=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Desejo sem sucesso de evacua\u00e7\u00e3o\"\n                            >\n                    Desejo sem sucesso de evacua\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt2063580\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt2063580\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt2063580]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1591681\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Formato de bolas\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1591681\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1591681]\"\n                                value=\"Formato de bolas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Formato de bolas\"\n                            >\n                    Formato de bolas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1423962\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Formato estreito\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1423962\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1423962]\"\n                                value=\"Formato estreito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Formato estreito\"\n                            >\n                    Formato estreito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1729824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Formato picado\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1729824\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1729824]\"\n                                value=\"Formato picado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Formato picado\"\n                            >\n                    Formato picado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1705321\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Formato plano\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1705321\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1705321]\"\n                                value=\"Formato plano\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Formato plano\"\n                            >\n                    Formato plano                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1469230\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Formato pastoso\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1469230\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1469230]\"\n                                value=\"Formato pastoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Formato pastoso\"\n                            >\n                    Formato pastoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1197009\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor amarela\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1197009\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1197009]\"\n                                value=\"Cor amarela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor amarela\"\n                            >\n                    Cor amarela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1594334\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor azulada\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1594334\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1594334]\"\n                                value=\"Cor azulada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor azulada\"\n                            >\n                    Cor azulada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1690415\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor branca\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1690415\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1690415]\"\n                                value=\"Cor branca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor branca\"\n                            >\n                    Cor branca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1422534\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor cinza\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1422534\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1422534]\"\n                                value=\"Cor cinza\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor cinza\"\n                            >\n                    Cor cinza                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt2025174\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor laranja\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt2025174\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt2025174]\"\n                                value=\"Cor laranja\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor laranja\"\n                            >\n                    Cor laranja                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1171192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor verde\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1171192\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1171192]\"\n                                value=\"Cor verde\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor verde\"\n                            >\n                    Cor verde                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1125149\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor marrom\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1125149\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1125149]\"\n                                value=\"Cor marrom\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor marrom\"\n                            >\n                    Cor marrom                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1106861\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Cor preta\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1106861\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1106861]\"\n                                value=\"Cor preta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Cor preta\"\n                            >\n                    Cor preta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2481233_2_opt1984519\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_2481233_2\" data-parsley-multiple=\"fld_2481233_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_2481233\"\n                                id=\"fld_2481233_2_opt1984519\"\n                                class=\"fld_2481233_2 option-required\"\n                                name=\"fld_2481233[opt1984519]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2481233_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2304231_2\" data-field-id=\"fld_2304231_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-45\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1996962\" class=\"form-group\" id=\"fld_1996962_2-wrap\">\r\n\t<label id=\"fld_1996962Label\" for=\"fld_1996962_2\" class=\"control-label\">Rins e Vias Urin\u00e1rias <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1691811\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"C\u00edrculos escuros sob os olhos\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1691811\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1691811]\"\n                                value=\"C\u00edrculos escuros sob os olhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"C\u00edrculos escuros sob os olhos\"\n                            >\n                    C\u00edrculos escuros sob os olhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1306639\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Levantar a noite para urinar uma vez\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1306639\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1306639]\"\n                                value=\"Levantar a noite para urinar uma vez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Levantar a noite para urinar uma vez\"\n                            >\n                    Levantar a noite para urinar uma vez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1326262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Levantar a noite para urinar mais de uma vez\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1326262\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1326262]\"\n                                value=\"Levantar a noite para urinar mais de uma vez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Levantar a noite para urinar mais de uma vez\"\n                            >\n                    Levantar a noite para urinar mais de uma vez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1533939\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1533939\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1533939]\"\n                                value=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Reten\u00e7\u00e3o de l\u00edquidos\"\n                            >\n                    Reten\u00e7\u00e3o de l\u00edquidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1800596\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o abundante\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1800596\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1800596]\"\n                                value=\"Mic\u00e7\u00e3o abundante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o abundante\"\n                            >\n                    Mic\u00e7\u00e3o abundante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1593350\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o escassa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1593350\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1593350]\"\n                                value=\"Mic\u00e7\u00e3o escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o escassa\"\n                            >\n                    Mic\u00e7\u00e3o escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1325615\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o excessiva\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1325615\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1325615]\"\n                                value=\"Mic\u00e7\u00e3o excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o excessiva\"\n                            >\n                    Mic\u00e7\u00e3o excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt2039729\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt2039729\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt2039729]\"\n                                value=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o involunt\u00e1ria\"\n                            >\n                    Mic\u00e7\u00e3o involunt\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1266565\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o dolorosa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1266565\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1266565]\"\n                                value=\"Mic\u00e7\u00e3o dolorosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o dolorosa\"\n                            >\n                    Mic\u00e7\u00e3o dolorosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1095793\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1095793\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1095793]\"\n                                value=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)\"\n                            >\n                    Mic\u00e7\u00e3o com sensa\u00e7\u00e3o de queima\u00e7\u00e3o (durante ou depois)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1647703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o dificultosa\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1647703\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1647703]\"\n                                value=\"Mic\u00e7\u00e3o dificultosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o dificultosa\"\n                            >\n                    Mic\u00e7\u00e3o dificultosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1560233\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o retardada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1560233\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1560233]\"\n                                value=\"Mic\u00e7\u00e3o retardada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o retardada\"\n                            >\n                    Mic\u00e7\u00e3o retardada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1497493\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o interrompida\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1497493\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1497493]\"\n                                value=\"Mic\u00e7\u00e3o interrompida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o interrompida\"\n                            >\n                    Mic\u00e7\u00e3o interrompida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1139652\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o em gotas\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1139652\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1139652]\"\n                                value=\"Mic\u00e7\u00e3o em gotas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o em gotas\"\n                            >\n                    Mic\u00e7\u00e3o em gotas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1502833\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1502833\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1502833]\"\n                                value=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Mic\u00e7\u00e3o obstru\u00edda\"\n                            >\n                    Mic\u00e7\u00e3o obstru\u00edda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt2077418\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Reten\u00e7\u00e3o de urina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt2077418\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt2077418]\"\n                                value=\"Reten\u00e7\u00e3o de urina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Reten\u00e7\u00e3o de urina\"\n                            >\n                    Reten\u00e7\u00e3o de urina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1448753\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Paralisia de urina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1448753\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1448753]\"\n                                value=\"Paralisia de urina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Paralisia de urina\"\n                            >\n                    Paralisia de urina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1316800\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Pedras nos rins\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1316800\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1316800]\"\n                                value=\"Pedras nos rins\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Pedras nos rins\"\n                            >\n                    Pedras nos rins                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1602922\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1602922\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1602922]\"\n                                value=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o urin\u00e1ria\"\n                            >\n                    Infec\u00e7\u00e3o urin\u00e1ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1535455\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina alcalina\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1535455\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1535455]\"\n                                value=\"Urina alcalina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina alcalina\"\n                            >\n                    Urina alcalina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1245702\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina acinzentada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1245702\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1245702]\"\n                                value=\"Urina acinzentada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina acinzentada\"\n                            >\n                    Urina acinzentada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1767736\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina alaranjada\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1767736\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1767736]\"\n                                value=\"Urina alaranjada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina alaranjada\"\n                            >\n                    Urina alaranjada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1617480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina escura ou turva\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1617480\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1617480]\"\n                                value=\"Urina escura ou turva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina escura ou turva\"\n                            >\n                    Urina escura ou turva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1153349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina com pus (nublada)\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1153349\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1153349]\"\n                                value=\"Urina com pus (nublada)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina com pus (nublada)\"\n                            >\n                    Urina com pus (nublada)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1981778\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina com sangue\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1981778\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1981778]\"\n                                value=\"Urina com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina com sangue\"\n                            >\n                    Urina com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt1150186\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina com odor adocicado\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt1150186\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt1150186]\"\n                                value=\"Urina com odor adocicado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina com odor adocicado\"\n                            >\n                    Urina com odor adocicado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt2023561\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Urina com odor forte\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt2023561\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt2023561]\"\n                                value=\"Urina com odor forte\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Urina com odor forte\"\n                            >\n                    Urina com odor forte                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1996962_2_opt2009239\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1996962_2\" data-parsley-multiple=\"fld_1996962_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1996962\"\n                                id=\"fld_1996962_2_opt2009239\"\n                                class=\"fld_1996962_2 option-required\"\n                                name=\"fld_1996962[opt2009239]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1996962_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6823998_2\" data-field-id=\"fld_6823998_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_4596590\" class=\"form-group\" id=\"fld_4596590_2-wrap\">\r\n\t<label id=\"fld_4596590Label\" for=\"fld_4596590_2\" class=\"control-label\">Artrite <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1699194\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1699194\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1699194]\"\n                                value=\"Dor - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Ombros\"\n                            >\n                    Dor - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1269183\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1269183\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1269183]\"\n                                value=\"Dor - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Pulsos\"\n                            >\n                    Dor - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt2000347\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt2000347\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt2000347]\"\n                                value=\"Dor - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - M\u00e3os\"\n                            >\n                    Dor - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1595429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1595429\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1595429]\"\n                                value=\"Dor - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Dedos das m\u00e3os\"\n                            >\n                    Dor - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1657992\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1657992\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1657992]\"\n                                value=\"Dor - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Joelhos\"\n                            >\n                    Dor - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1692539\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1692539\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1692539]\"\n                                value=\"Dor - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Pernas\"\n                            >\n                    Dor - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1992237\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1992237\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1992237]\"\n                                value=\"Dor - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Tornozelos\"\n                            >\n                    Dor - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt2068651\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt2068651\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt2068651]\"\n                                value=\"Dor - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - P\u00e9s\"\n                            >\n                    Dor - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1566573\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Dor - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1566573\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1566573]\"\n                                value=\"Dor - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Dor - Dedos dos p\u00e9s\"\n                            >\n                    Dor - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1274377\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1274377\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1274377]\"\n                                value=\"Incha\u00e7o - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Ombros\"\n                            >\n                    Incha\u00e7o - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt2052296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt2052296\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt2052296]\"\n                                value=\"Incha\u00e7o - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Pulsos\"\n                            >\n                    Incha\u00e7o - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1226478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1226478\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1226478]\"\n                                value=\"Incha\u00e7o - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - M\u00e3os\"\n                            >\n                    Incha\u00e7o - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1129380\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1129380\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1129380]\"\n                                value=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Dedos das m\u00e3os\"\n                            >\n                    Incha\u00e7o - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1231438\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1231438\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1231438]\"\n                                value=\"Incha\u00e7o - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Joelhos\"\n                            >\n                    Incha\u00e7o - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1180671\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1180671\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1180671]\"\n                                value=\"Incha\u00e7o - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Pernas\"\n                            >\n                    Incha\u00e7o - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1577258\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1577258\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1577258]\"\n                                value=\"Incha\u00e7o - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Tornozelos\"\n                            >\n                    Incha\u00e7o - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1620672\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1620672\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1620672]\"\n                                value=\"Incha\u00e7o - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - P\u00e9s\"\n                            >\n                    Incha\u00e7o - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1984597\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1984597\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1984597]\"\n                                value=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Incha\u00e7o - Dedos dos p\u00e9s\"\n                            >\n                    Incha\u00e7o - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1868483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Ombros\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1868483\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1868483]\"\n                                value=\"Enrijecimento - Ombros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Ombros\"\n                            >\n                    Enrijecimento - Ombros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1676038\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Pulsos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1676038\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1676038]\"\n                                value=\"Enrijecimento - Pulsos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Pulsos\"\n                            >\n                    Enrijecimento - Pulsos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1255321\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - M\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1255321\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1255321]\"\n                                value=\"Enrijecimento - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - M\u00e3os\"\n                            >\n                    Enrijecimento - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1413930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Dedos das m\u00e3os\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1413930\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1413930]\"\n                                value=\"Enrijecimento - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Dedos das m\u00e3os\"\n                            >\n                    Enrijecimento - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1663405\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Joelhos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1663405\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1663405]\"\n                                value=\"Enrijecimento - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Joelhos\"\n                            >\n                    Enrijecimento - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1675771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Pernas\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1675771\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1675771]\"\n                                value=\"Enrijecimento - Pernas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Pernas\"\n                            >\n                    Enrijecimento - Pernas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1897509\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Tornozelos\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1897509\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1897509]\"\n                                value=\"Enrijecimento - Tornozelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Tornozelos\"\n                            >\n                    Enrijecimento - Tornozelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1261729\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - P\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1261729\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1261729]\"\n                                value=\"Enrijecimento - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - P\u00e9s\"\n                            >\n                    Enrijecimento - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1728510\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Enrijecimento - Dedos dos p\u00e9s\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1728510\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1728510]\"\n                                value=\"Enrijecimento - Dedos dos p\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Enrijecimento - Dedos dos p\u00e9s\"\n                            >\n                    Enrijecimento - Dedos dos p\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1120034\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1120034\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1120034]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4596590_2_opt1542226\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4596590_2\" data-parsley-multiple=\"fld_4596590_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4596590\"\n                                id=\"fld_4596590_2_opt1542226\"\n                                class=\"fld_4596590_2 option-required\"\n                                name=\"fld_4596590[opt1542226]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4596590_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2377312_2\" data-field-id=\"fld_2377312_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-46\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7925824\" class=\"form-group\" id=\"fld_7925824_2-wrap\">\r\n\t<label id=\"fld_7925824Label\" for=\"fld_7925824_2\" class=\"control-label\">Articula\u00e7\u00f5es, \u00d3sseas e Muscular <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt2070517\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor lombar (superior ou inferior)\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt2070517\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt2070517]\"\n                                value=\"Dor lombar (superior ou inferior)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor lombar (superior ou inferior)\"\n                            >\n                    Dor lombar (superior ou inferior)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1879733\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Ossos quebrados (atualmente ou recuperados)\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1879733\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1879733]\"\n                                value=\"Ossos quebrados (atualmente ou recuperados)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Ossos quebrados (atualmente ou recuperados)\"\n                            >\n                    Ossos quebrados (atualmente ou recuperados)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1156486\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Osteoartrite\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1156486\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1156486]\"\n                                value=\"Osteoartrite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Osteoartrite\"\n                            >\n                    Osteoartrite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1529985\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Artrite reumatoide\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1529985\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1529985]\"\n                                value=\"Artrite reumatoide\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Artrite reumatoide\"\n                            >\n                    Artrite reumatoide                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1328416\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Rigidez nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1328416\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1328416]\"\n                                value=\"Rigidez nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Rigidez nas articula\u00e7\u00f5es\"\n                            >\n                    Rigidez nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1118223\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1118223\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1118223]\"\n                                value=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Incha\u00e7o nas articula\u00e7\u00f5es\"\n                            >\n                    Incha\u00e7o nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1125281\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor nas articula\u00e7\u00f5es\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1125281\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1125281]\"\n                                value=\"Dor nas articula\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor nas articula\u00e7\u00f5es\"\n                            >\n                    Dor nas articula\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt2085805\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor muscular\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt2085805\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt2085805]\"\n                                value=\"Dor muscular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor muscular\"\n                            >\n                    Dor muscular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1580703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor no pesco\u00e7o\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1580703\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1580703]\"\n                                value=\"Dor no pesco\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor no pesco\u00e7o\"\n                            >\n                    Dor no pesco\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1557488\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor nas costas\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1557488\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1557488]\"\n                                value=\"Dor nas costas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor nas costas\"\n                            >\n                    Dor nas costas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1693479\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Dor na face\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1693479\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1693479]\"\n                                value=\"Dor na face\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Dor na face\"\n                            >\n                    Dor na face                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1327275\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1327275\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1327275]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7925824_2_opt1864395\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_7925824_2\" data-parsley-multiple=\"fld_7925824_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_7925824\"\n                                id=\"fld_7925824_2_opt1864395\"\n                                class=\"fld_7925824_2 option-required\"\n                                name=\"fld_7925824[opt1864395]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7925824_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_4147300_2\" data-field-id=\"fld_4147300_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9756699\" class=\"form-group\" id=\"fld_9756699_2-wrap\">\r\n\t<label id=\"fld_9756699Label\" for=\"fld_9756699_2\" class=\"control-label\">Ouvidos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1470447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Cera excessiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1470447\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1470447]\"\n                                value=\"Cera excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Cera excessiva\"\n                            >\n                    Cera excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1791762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Coceira no canal auditivo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1791762\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1791762]\"\n                                value=\"Coceira no canal auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Coceira no canal auditivo\"\n                            >\n                    Coceira no canal auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1991209\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema no canal auditivo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1991209\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1991209]\"\n                                value=\"Eczema no canal auditivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Eczema no canal auditivo\"\n                            >\n                    Eczema no canal auditivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1754078\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Dor atr\u00e1s\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1754078\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1754078]\"\n                                value=\"Dor atr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Dor atr\u00e1s\"\n                            >\n                    Dor atr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1695221\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Dor do lado direito\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1695221\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1695221]\"\n                                value=\"Dor do lado direito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Dor do lado direito\"\n                            >\n                    Dor do lado direito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1435185\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Dor do lado esquerdo\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1435185\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1435185]\"\n                                value=\"Dor do lado esquerdo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Dor do lado esquerdo\"\n                            >\n                    Dor do lado esquerdo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1114533\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Flu\u00eddos\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1114533\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1114533]\"\n                                value=\"Flu\u00eddos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Flu\u00eddos\"\n                            >\n                    Flu\u00eddos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1464530\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Inflama\u00e7\u00e3o\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1464530\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1464530]\"\n                                value=\"Inflama\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Inflama\u00e7\u00e3o\"\n                            >\n                    Inflama\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1180522\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o recorrente\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1180522\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1180522]\"\n                                value=\"Infec\u00e7\u00e3o recorrente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o recorrente\"\n                            >\n                    Infec\u00e7\u00e3o recorrente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1247581\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Zumbido\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1247581\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1247581]\"\n                                value=\"Zumbido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Zumbido\"\n                            >\n                    Zumbido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1216123\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Ru\u00eddos\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1216123\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1216123]\"\n                                value=\"Ru\u00eddos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Ru\u00eddos\"\n                            >\n                    Ru\u00eddos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1645416\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Defici\u00eancia auditiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1645416\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1645416]\"\n                                value=\"Defici\u00eancia auditiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Defici\u00eancia auditiva\"\n                            >\n                    Defici\u00eancia auditiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1277862\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Perda auditiva\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1277862\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1277862]\"\n                                value=\"Perda auditiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Perda auditiva\"\n                            >\n                    Perda auditiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1633597\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1633597\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1633597]\"\n                                value=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Orelhas - Ulcera\u00e7\u00e3o na frente\"\n                            >\n                    Orelhas - Ulcera\u00e7\u00e3o na frente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1212164\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1212164\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1212164]\"\n                                value=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s\"\n                            >\n                    Orelhas - Erup\u00e7\u00e3o ou eczema atr\u00e1s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1487107\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Orelhas - Outros problemas\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1487107\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1487107]\"\n                                value=\"Orelhas - Outros problemas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Orelhas - Outros problemas\"\n                            >\n                    Orelhas - Outros problemas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1053055\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1053055\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1053055]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9756699_2_opt1319779\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9756699_2\" data-parsley-multiple=\"fld_9756699_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9756699\"\n                                id=\"fld_9756699_2_opt1319779\"\n                                class=\"fld_9756699_2 option-required\"\n                                name=\"fld_9756699[opt1319779]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9756699_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_6128378_2\" data-field-id=\"fld_6128378_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-47\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5201432\" class=\"form-group\" id=\"fld_5201432_2-wrap\">\r\n\t<label id=\"fld_5201432Label\" for=\"fld_5201432_2\" class=\"control-label\">Olhos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1702665\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edveis\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1702665\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1702665]\"\n                                value=\"Sens\u00edveis\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Sens\u00edveis\"\n                            >\n                    Sens\u00edveis                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1300715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Coceira\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1300715\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1300715]\"\n                                value=\"Coceira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Coceira\"\n                            >\n                    Coceira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1243192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Descargas\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1243192\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1243192]\"\n                                value=\"Descargas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Descargas\"\n                            >\n                    Descargas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1424542\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Queima\u00e7\u00e3o\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1424542\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1424542]\"\n                                value=\"Queima\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Queima\u00e7\u00e3o\"\n                            >\n                    Queima\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1840502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Dor\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1840502\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1840502]\"\n                                value=\"Dor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Dor\"\n                            >\n                    Dor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1450274\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Secos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1450274\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1450274]\"\n                                value=\"Secos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Secos\"\n                            >\n                    Secos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1548588\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Marejados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1548588\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1548588]\"\n                                value=\"Marejados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Marejados\"\n                            >\n                    Marejados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt2061189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Aguados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt2061189\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt2061189]\"\n                                value=\"Aguados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Aguados\"\n                            >\n                    Aguados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1531376\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Afundados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1531376\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1531376]\"\n                                value=\"Afundados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Afundados\"\n                            >\n                    Afundados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1091312\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Vermelhos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1091312\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1091312]\"\n                                value=\"Vermelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Vermelhos\"\n                            >\n                    Vermelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1631585\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Sujeira\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1631585\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1631585]\"\n                                value=\"Sujeira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Sujeira\"\n                            >\n                    Sujeira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt2061891\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Miopia \"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt2061891\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt2061891]\"\n                                value=\"Miopia \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Miopia \"\n                            >\n                    Miopia                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1395599\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Diplopia \"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1395599\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1395599]\"\n                                value=\"Diplopia \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Diplopia \"\n                            >\n                    Diplopia                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1719212\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Estrabismo\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1719212\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1719212]\"\n                                value=\"Estrabismo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Estrabismo\"\n                            >\n                    Estrabismo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1349457\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Fotofobia\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1349457\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1349457]\"\n                                value=\"Fotofobia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Fotofobia\"\n                            >\n                    Fotofobia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1736109\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o fraca\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1736109\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1736109]\"\n                                value=\"Vis\u00e3o fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Vis\u00e3o fraca\"\n                            >\n                    Vis\u00e3o fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1216680\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o turva\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1216680\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1216680]\"\n                                value=\"Vis\u00e3o turva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Vis\u00e3o turva\"\n                            >\n                    Vis\u00e3o turva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1590813\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o tunelada\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1590813\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1590813]\"\n                                value=\"Vis\u00e3o tunelada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Vis\u00e3o tunelada\"\n                            >\n                    Vis\u00e3o tunelada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1834218\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Vis\u00e3o falhando ou em agravamento\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1834218\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1834218]\"\n                                value=\"Vis\u00e3o falhando ou em agravamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Vis\u00e3o falhando ou em agravamento\"\n                            >\n                    Vis\u00e3o falhando ou em agravamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt2057082\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Sangramento\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt2057082\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt2057082]\"\n                                value=\"Sangramento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Sangramento\"\n                            >\n                    Sangramento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1935262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"P\u00e1lpebras inchadas\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1935262\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1935262]\"\n                                value=\"P\u00e1lpebras inchadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"P\u00e1lpebras inchadas\"\n                            >\n                    P\u00e1lpebras inchadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1899376\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Escuro sob os olhos\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1899376\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1899376]\"\n                                value=\"Escuro sob os olhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Escuro sob os olhos\"\n                            >\n                    Escuro sob os olhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1603109\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1603109\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1603109]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5201432_2_opt1344095\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5201432_2\" data-parsley-multiple=\"fld_5201432_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5201432\"\n                                id=\"fld_5201432_2_opt1344095\"\n                                class=\"fld_5201432_2 option-required\"\n                                name=\"fld_5201432[opt1344095]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5201432_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7039225_2\" data-field-id=\"fld_7039225_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1904780\" class=\"form-group\" id=\"fld_1904780_2-wrap\">\r\n\t<label id=\"fld_1904780Label\" for=\"fld_1904780_2\" class=\"control-label\">Nariz <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1059988\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Longo\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1059988\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1059988]\"\n                                value=\"Longo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Longo\"\n                            >\n                    Longo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1771630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Torto\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1771630\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1771630]\"\n                                value=\"Torto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Torto\"\n                            >\n                    Torto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1631600\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Ponta fria\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1631600\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1631600]\"\n                                value=\"Ponta fria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Ponta fria\"\n                            >\n                    Ponta fria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1858031\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Ponta vermelha\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1858031\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1858031]\"\n                                value=\"Ponta vermelha\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Ponta vermelha\"\n                            >\n                    Ponta vermelha                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1202958\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edvel a odores\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1202958\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1202958]\"\n                                value=\"Sens\u00edvel a odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Sens\u00edvel a odores\"\n                            >\n                    Sens\u00edvel a odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt2013506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Narina seca\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt2013506\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt2013506]\"\n                                value=\"Narina seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Narina seca\"\n                            >\n                    Narina seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1991210\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Secre\u00e7\u00e3o seca\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1991210\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1991210]\"\n                                value=\"Secre\u00e7\u00e3o seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Secre\u00e7\u00e3o seca\"\n                            >\n                    Secre\u00e7\u00e3o seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1062391\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade em respirar\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1062391\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1062391]\"\n                                value=\"Dificuldade em respirar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Dificuldade em respirar\"\n                            >\n                    Dificuldade em respirar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt2076560\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Congestionado\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt2076560\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt2076560]\"\n                                value=\"Congestionado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Congestionado\"\n                            >\n                    Congestionado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1241777\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1241777\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1241777]\"\n                                value=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Infec\u00e7\u00e3o do s\u00ednus (sinusite)\"\n                            >\n                    Infec\u00e7\u00e3o do s\u00ednus (sinusite)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1534493\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1534493\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1534493]\"\n                                value=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos\"\n                            >\n                    Obstru\u00e7\u00e3o dos p\u00f3lipos a\u00e9reos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1195709\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1195709\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1195709]\"\n                                value=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Descarga de secre\u00e7\u00e3o na narina direita\"\n                            >\n                    Descarga de secre\u00e7\u00e3o na narina direita                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1737232\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1737232\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1737232]\"\n                                value=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Descarga de secre\u00e7\u00e3o na narina esquerda\"\n                            >\n                    Descarga de secre\u00e7\u00e3o na narina esquerda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1341485\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Gotejamento p\u00f3s-nasal\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1341485\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1341485]\"\n                                value=\"Gotejamento p\u00f3s-nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Gotejamento p\u00f3s-nasal\"\n                            >\n                    Gotejamento p\u00f3s-nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1416185\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"\u00dalceras\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1416185\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1416185]\"\n                                value=\"\u00dalceras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"\u00dalceras\"\n                            >\n                    \u00dalceras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1496051\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Congestionado com sangue\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1496051\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1496051]\"\n                                value=\"Congestionado com sangue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Congestionado com sangue\"\n                            >\n                    Congestionado com sangue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1977715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Sangramento nasal\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1977715\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1977715]\"\n                                value=\"Sangramento nasal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Sangramento nasal\"\n                            >\n                    Sangramento nasal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1335797\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1335797\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1335797]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1904780_2_opt1546581\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1904780_2\" data-parsley-multiple=\"fld_1904780_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1904780\"\n                                id=\"fld_1904780_2_opt1546581\"\n                                class=\"fld_1904780_2 option-required\"\n                                name=\"fld_1904780[opt1546581]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1904780_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_224762_2\" data-field-id=\"fld_224762_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-48\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_1289525\" class=\"form-group\" id=\"fld_1289525_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_1289525\" id=\"fld_1289525_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_1289525\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_1289525\" id=\"fld_1289525_2_btn\" value=\"\" data-field=\"fld_1289525\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3354932\" class=\"form-group\" id=\"fld_3354932_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_3354932\" id=\"fld_3354932_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_3354932\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_3354932\" id=\"fld_3354932_2_btn\" value=\"\" data-field=\"fld_3354932\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_3152327\" class=\"form-group\" id=\"fld_3152327_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_3152327\" id=\"fld_3152327_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_3152327\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_3152327\" id=\"fld_3152327_2_btn\" value=\"\" data-field=\"fld_3152327\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_9\" data-formpage=\"9\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_9\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-49\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1633260\" class=\"form-group\" id=\"fld_1633260_2-wrap\">\r\n\t<label id=\"fld_1633260Label\" for=\"fld_1633260_2\" class=\"control-label\">L\u00e1bios, Boca e Dentes <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1212738\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios inchados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1212738\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1212738]\"\n                                value=\"L\u00e1bios inchados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00e1bios inchados\"\n                            >\n                    L\u00e1bios inchados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt2058227\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios rachados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt2058227\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt2058227]\"\n                                value=\"L\u00e1bios rachados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00e1bios rachados\"\n                            >\n                    L\u00e1bios rachados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt2088266\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00e1bios secos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt2088266\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt2088266]\"\n                                value=\"L\u00e1bios secos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00e1bios secos\"\n                            >\n                    L\u00e1bios secos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1451843\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Herpes labial\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1451843\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1451843]\"\n                                value=\"Herpes labial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Herpes labial\"\n                            >\n                    Herpes labial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1704766\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Mau h\u00e1lito\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1704766\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1704766]\"\n                                value=\"Mau h\u00e1lito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Mau h\u00e1lito\"\n                            >\n                    Mau h\u00e1lito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt2069487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Gosto amargo\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt2069487\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt2069487]\"\n                                value=\"Gosto amargo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Gosto amargo\"\n                            >\n                    Gosto amargo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1301843\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Afta\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1301843\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1301843]\"\n                                value=\"Afta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Afta\"\n                            >\n                    Afta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt2089863\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"\u00dalcera\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt2089863\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt2089863]\"\n                                value=\"\u00dalcera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"\u00dalcera\"\n                            >\n                    \u00dalcera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1946794\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua para fora\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1946794\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1946794]\"\n                                value=\"L\u00edngua para fora\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00edngua para fora\"\n                            >\n                    L\u00edngua para fora                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1385555\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua descolorada\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1385555\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1385555]\"\n                                value=\"L\u00edngua descolorada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00edngua descolorada\"\n                            >\n                    L\u00edngua descolorada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1418437\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00edngua com feridas\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1418437\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1418437]\"\n                                value=\"L\u00edngua com feridas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"L\u00edngua com feridas\"\n                            >\n                    L\u00edngua com feridas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1375826\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Boca seca\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1375826\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1375826]\"\n                                value=\"Boca seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Boca seca\"\n                            >\n                    Boca seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1843526\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Saliva\u00e7\u00e3o excessiva\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1843526\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1843526]\"\n                                value=\"Saliva\u00e7\u00e3o excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Saliva\u00e7\u00e3o excessiva\"\n                            >\n                    Saliva\u00e7\u00e3o excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1337285\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Babando\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1337285\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1337285]\"\n                                value=\"Babando\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Babando\"\n                            >\n                    Babando                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1709296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade na fala\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1709296\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1709296]\"\n                                value=\"Dificuldade na fala\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dificuldade na fala\"\n                            >\n                    Dificuldade na fala                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt2054780\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes retangulares\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt2054780\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt2054780]\"\n                                value=\"Dentes retangulares\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes retangulares\"\n                            >\n                    Dentes retangulares                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1406420\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes curtos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1406420\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1406420]\"\n                                value=\"Dentes curtos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes curtos\"\n                            >\n                    Dentes curtos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1235535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes longos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1235535\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1235535]\"\n                                value=\"Dentes longos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes longos\"\n                            >\n                    Dentes longos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1960296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes assim\u00e9tricos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1960296\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1960296]\"\n                                value=\"Dentes assim\u00e9tricos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes assim\u00e9tricos\"\n                            >\n                    Dentes assim\u00e9tricos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1602653\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes amarelados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1602653\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1602653]\"\n                                value=\"Dentes amarelados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes amarelados\"\n                            >\n                    Dentes amarelados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1126303\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes verdes\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1126303\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1126303]\"\n                                value=\"Dentes verdes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes verdes\"\n                            >\n                    Dentes verdes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1424003\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes pretos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1424003\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1424003]\"\n                                value=\"Dentes pretos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes pretos\"\n                            >\n                    Dentes pretos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1666021\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes soltos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1666021\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1666021]\"\n                                value=\"Dentes soltos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes soltos\"\n                            >\n                    Dentes soltos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1749860\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes perdidos\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1749860\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1749860]\"\n                                value=\"Dentes perdidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes perdidos\"\n                            >\n                    Dentes perdidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1891015\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1891015\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1891015]\"\n                                value=\"Dentes sens\u00edveis\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes sens\u00edveis\"\n                            >\n                    Dentes sens\u00edveis                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1992471\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis ao frio\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1992471\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1992471]\"\n                                value=\"Dentes sens\u00edveis ao frio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes sens\u00edveis ao frio\"\n                            >\n                    Dentes sens\u00edveis ao frio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1064182\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1064182\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1064182]\"\n                                value=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes sens\u00edveis a mastiga\u00e7\u00e3o\"\n                            >\n                    Dentes sens\u00edveis a mastiga\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1174082\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Dentes com numerosas c\u00e1ries\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1174082\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1174082]\"\n                                value=\"Dentes com numerosas c\u00e1ries\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Dentes com numerosas c\u00e1ries\"\n                            >\n                    Dentes com numerosas c\u00e1ries                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1125627\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Ranger dos dentes (bruxismo)\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1125627\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1125627]\"\n                                value=\"Ranger dos dentes (bruxismo)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Ranger dos dentes (bruxismo)\"\n                            >\n                    Ranger dos dentes (bruxismo)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1793466\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Abscesso na gengiva\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1793466\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1793466]\"\n                                value=\"Abscesso na gengiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Abscesso na gengiva\"\n                            >\n                    Abscesso na gengiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1828344\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Sangramento gengival\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1828344\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1828344]\"\n                                value=\"Sangramento gengival\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Sangramento gengival\"\n                            >\n                    Sangramento gengival                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1731016\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1731016\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1731016]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1633260_2_opt1642604\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1633260_2\" data-parsley-multiple=\"fld_1633260_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1633260\"\n                                id=\"fld_1633260_2_opt1642604\"\n                                class=\"fld_1633260_2 option-required\"\n                                name=\"fld_1633260[opt1642604]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1633260_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_973027_2\" data-field-id=\"fld_973027_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9478261\" class=\"form-group\" id=\"fld_9478261_2-wrap\">\r\n\t<label id=\"fld_9478261Label\" for=\"fld_9478261_2\" class=\"control-label\">Garganta <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt2061916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Dor de garganta\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt2061916\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt2061916]\"\n                                value=\"Dor de garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Dor de garganta\"\n                            >\n                    Dor de garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1721721\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Garganta inflamada\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1721721\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1721721]\"\n                                value=\"Garganta inflamada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Garganta inflamada\"\n                            >\n                    Garganta inflamada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1956052\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Garganta infeccionada\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1956052\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1956052]\"\n                                value=\"Garganta infeccionada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Garganta infeccionada\"\n                            >\n                    Garganta infeccionada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1771132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Garganta seca\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1771132\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1771132]\"\n                                value=\"Garganta seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Garganta seca\"\n                            >\n                    Garganta seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1239192\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Muco excessivo\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1239192\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1239192]\"\n                                value=\"Muco excessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Muco excessivo\"\n                            >\n                    Muco excessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1805943\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Ferida\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1805943\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1805943]\"\n                                value=\"Ferida\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Ferida\"\n                            >\n                    Ferida                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1930858\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de degluti\u00e7\u00e3o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1930858\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1930858]\"\n                                value=\"Dificuldade de degluti\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Dificuldade de degluti\u00e7\u00e3o\"\n                            >\n                    Dificuldade de degluti\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1203693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Dor ao deglutir\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1203693\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1203693]\"\n                                value=\"Dor ao deglutir\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Dor ao deglutir\"\n                            >\n                    Dor ao deglutir                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1828090\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Rouquid\u00e3o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1828090\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1828090]\"\n                                value=\"Rouquid\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Rouquid\u00e3o\"\n                            >\n                    Rouquid\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1141114\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Perda de voz\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1141114\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1141114]\"\n                                value=\"Perda de voz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Perda de voz\"\n                            >\n                    Perda de voz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1131794\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de asfixia\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1131794\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1131794]\"\n                                value=\"Sensa\u00e7\u00e3o de asfixia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de asfixia\"\n                            >\n                    Sensa\u00e7\u00e3o de asfixia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt2029156\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt2029156\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt2029156]\"\n                                value=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de caro\u00e7o\"\n                            >\n                    Sensa\u00e7\u00e3o de caro\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1711950\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Sensa\u00e7\u00e3o de estreitamento\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1711950\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1711950]\"\n                                value=\"Sensa\u00e7\u00e3o de estreitamento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Sensa\u00e7\u00e3o de estreitamento\"\n                            >\n                    Sensa\u00e7\u00e3o de estreitamento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt2005930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Amigdalite\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt2005930\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt2005930]\"\n                                value=\"Amigdalite\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Amigdalite\"\n                            >\n                    Amigdalite                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1086026\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Aden\u00f3ides\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1086026\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1086026]\"\n                                value=\"Aden\u00f3ides\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Aden\u00f3ides\"\n                            >\n                    Aden\u00f3ides                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1647454\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1647454\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1647454]\"\n                                value=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Externo - Endurecimento das gl\u00e2ndulas\"\n                            >\n                    Externo - Endurecimento das gl\u00e2ndulas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt2068101\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt2068101\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt2068101]\"\n                                value=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta\"\n                            >\n                    Externo - Sensa\u00e7\u00e3o de n\u00f3 na garganta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1338042\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Externo - B\u00f3cio\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1338042\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1338042]\"\n                                value=\"Externo - B\u00f3cio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Externo - B\u00f3cio\"\n                            >\n                    Externo - B\u00f3cio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1406752\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1406752\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1406752]\"\n                                value=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Externo - Dor na gl\u00e2ndula tire\u00f3ide\"\n                            >\n                    Externo - Dor na gl\u00e2ndula tire\u00f3ide                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1450963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1450963\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1450963]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9478261_2_opt1558277\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9478261_2\" data-parsley-multiple=\"fld_9478261_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9478261\"\n                                id=\"fld_9478261_2_opt1558277\"\n                                class=\"fld_9478261_2 option-required\"\n                                name=\"fld_9478261[opt1558277]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9478261_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7301016_2\" data-field-id=\"fld_7301016_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-50\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_78322\" class=\"form-group\" id=\"fld_78322_2-wrap\">\r\n\t<label id=\"fld_78322Label\" for=\"fld_78322_2\" class=\"control-label\">Pele <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1512013\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Saud\u00e1vel\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1512013\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1512013]\"\n                                value=\"Saud\u00e1vel\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Saud\u00e1vel\"\n                            >\n                    Saud\u00e1vel                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1426853\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Corada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1426853\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1426853]\"\n                                value=\"Corada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Corada\"\n                            >\n                    Corada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1259630\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Descolorada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1259630\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1259630]\"\n                                value=\"Descolorada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Descolorada\"\n                            >\n                    Descolorada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt2005373\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Sardas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt2005373\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt2005373]\"\n                                value=\"Sardas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Sardas\"\n                            >\n                    Sardas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1544480\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Machada\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1544480\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1544480]\"\n                                value=\"Machada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Machada\"\n                            >\n                    Machada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1928177\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Seca\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1928177\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1928177]\"\n                                value=\"Seca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Seca\"\n                            >\n                    Seca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1359303\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Oleosa\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1359303\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1359303]\"\n                                value=\"Oleosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Oleosa\"\n                            >\n                    Oleosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1384394\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Sudorese excessiva\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1384394\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1384394]\"\n                                value=\"Sudorese excessiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Sudorese excessiva\"\n                            >\n                    Sudorese excessiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1962010\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Fina\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1962010\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1962010]\"\n                                value=\"Fina\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Fina\"\n                            >\n                    Fina                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1871125\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Porcelana\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1871125\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1871125]\"\n                                value=\"Porcelana\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Porcelana\"\n                            >\n                    Porcelana                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1702484\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Coceira\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1702484\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1702484]\"\n                                value=\"Coceira\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Coceira\"\n                            >\n                    Coceira                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1195639\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Acne (espinhas e cravos)\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1195639\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1195639]\"\n                                value=\"Acne (espinhas e cravos)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Acne (espinhas e cravos)\"\n                            >\n                    Acne (espinhas e cravos)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1869944\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Verrugas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1869944\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1869944]\"\n                                value=\"Verrugas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Verrugas\"\n                            >\n                    Verrugas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1528943\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Prurido\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1528943\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1528943]\"\n                                value=\"Prurido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Prurido\"\n                            >\n                    Prurido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1153594\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Urtic\u00e1rias\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1153594\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1153594]\"\n                                value=\"Urtic\u00e1rias\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Urtic\u00e1rias\"\n                            >\n                    Urtic\u00e1rias                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1824266\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Fur\u00fanculos\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1824266\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1824266]\"\n                                value=\"Fur\u00fanculos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Fur\u00fanculos\"\n                            >\n                    Fur\u00fanculos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1878526\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Psoriase\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1878526\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1878526]\"\n                                value=\"Psoriase\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Psoriase\"\n                            >\n                    Psoriase                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1815649\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Cistos\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1815649\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1815649]\"\n                                value=\"Cistos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Cistos\"\n                            >\n                    Cistos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1691667\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Infec\u00e7\u00f5es\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1691667\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1691667]\"\n                                value=\"Infec\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Infec\u00e7\u00f5es\"\n                            >\n                    Infec\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1050669\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1050669\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1050669]\"\n                                value=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Erup\u00e7\u00f5es cut\u00e2neas\"\n                            >\n                    Erup\u00e7\u00f5es cut\u00e2neas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1315707\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Veias varicosas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1315707\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1315707]\"\n                                value=\"Veias varicosas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Veias varicosas\"\n                            >\n                    Veias varicosas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1925880\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Veias quebradas\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1925880\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1925880]\"\n                                value=\"Veias quebradas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Veias quebradas\"\n                            >\n                    Veias quebradas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1907849\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1907849\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1907849]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_78322_2_opt1220515\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_78322_2\" data-parsley-multiple=\"fld_78322_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_78322\"\n                                id=\"fld_78322_2_opt1220515\"\n                                class=\"fld_78322_2 option-required\"\n                                name=\"fld_78322[opt1220515]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_78322_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1855499_2\" data-field-id=\"fld_1855499_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6108732\" class=\"form-group\" id=\"fld_6108732_2-wrap\">\r\n\t<label id=\"fld_6108732Label\" for=\"fld_6108732_2\" class=\"control-label\">Eczema, Psor\u00edase e Comich\u00e3o <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1238487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Rosto\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1238487\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1238487]\"\n                                value=\"Eczema - Rosto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Rosto\"\n                            >\n                    Eczema - Rosto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1396127\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Pesco\u00e7o\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1396127\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1396127]\"\n                                value=\"Eczema - Pesco\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Pesco\u00e7o\"\n                            >\n                    Eczema - Pesco\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1050856\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Bra\u00e7o\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1050856\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1050856]\"\n                                value=\"Eczema - Bra\u00e7o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Bra\u00e7o\"\n                            >\n                    Eczema - Bra\u00e7o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1164181\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - M\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1164181\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1164181]\"\n                                value=\"Eczema - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - M\u00e3os\"\n                            >\n                    Eczema - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1470740\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Dedos das m\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1470740\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1470740]\"\n                                value=\"Eczema - Dedos das m\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Dedos das m\u00e3os\"\n                            >\n                    Eczema - Dedos das m\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1241502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Perna\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1241502\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1241502]\"\n                                value=\"Eczema - Perna\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Perna\"\n                            >\n                    Eczema - Perna                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1154167\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1154167\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1154167]\"\n                                value=\"Eczema - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - P\u00e9s\"\n                            >\n                    Eczema - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1363616\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Dedo dos P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1363616\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1363616]\"\n                                value=\"Eczema - Dedo dos P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Dedo dos P\u00e9s\"\n                            >\n                    Eczema - Dedo dos P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1365821\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - Genitais\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1365821\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1365821]\"\n                                value=\"Eczema - Genitais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - Genitais\"\n                            >\n                    Eczema - Genitais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1939514\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Eczema - \u00c2nus\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1939514\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1939514]\"\n                                value=\"Eczema - \u00c2nus\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Eczema - \u00c2nus\"\n                            >\n                    Eczema - \u00c2nus                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt2040612\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase -  Cotovelo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt2040612\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt2040612]\"\n                                value=\"Psor\u00edase -  Cotovelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Psor\u00edase -  Cotovelo\"\n                            >\n                    Psor\u00edase -  Cotovelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1210397\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Dobra do cotovelo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1210397\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1210397]\"\n                                value=\"Psor\u00edase - Dobra do cotovelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Psor\u00edase - Dobra do cotovelo\"\n                            >\n                    Psor\u00edase - Dobra do cotovelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1871285\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Joelho\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1871285\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1871285]\"\n                                value=\"Psor\u00edase - Joelho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Psor\u00edase - Joelho\"\n                            >\n                    Psor\u00edase - Joelho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1124039\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Psor\u00edase - Dobra do joelho\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1124039\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1124039]\"\n                                value=\"Psor\u00edase - Dobra do joelho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Psor\u00edase - Dobra do joelho\"\n                            >\n                    Psor\u00edase - Dobra do joelho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1078232\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Couro cabeludo\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1078232\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1078232]\"\n                                value=\"Comich\u00e3o - Couro cabeludo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - Couro cabeludo\"\n                            >\n                    Comich\u00e3o - Couro cabeludo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1569762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Rosto\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1569762\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1569762]\"\n                                value=\"Comich\u00e3o - Rosto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - Rosto\"\n                            >\n                    Comich\u00e3o - Rosto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1760304\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Cotovelos\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1760304\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1760304]\"\n                                value=\"Comich\u00e3o - Cotovelos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - Cotovelos\"\n                            >\n                    Comich\u00e3o - Cotovelos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1710701\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - M\u00e3os\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1710701\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1710701]\"\n                                value=\"Comich\u00e3o - M\u00e3os\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - M\u00e3os\"\n                            >\n                    Comich\u00e3o - M\u00e3os                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1501755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - Joelhos\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1501755\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1501755]\"\n                                value=\"Comich\u00e3o - Joelhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - Joelhos\"\n                            >\n                    Comich\u00e3o - Joelhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1371984\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Comich\u00e3o - P\u00e9s\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1371984\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1371984]\"\n                                value=\"Comich\u00e3o - P\u00e9s\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Comich\u00e3o - P\u00e9s\"\n                            >\n                    Comich\u00e3o - P\u00e9s                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1442481\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1442481\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1442481]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6108732_2_opt1440402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6108732_2\" data-parsley-multiple=\"fld_6108732_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6108732\"\n                                id=\"fld_6108732_2_opt1440402\"\n                                class=\"fld_6108732_2 option-required\"\n                                name=\"fld_6108732[opt1440402]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6108732_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9690541_2\" data-field-id=\"fld_9690541_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-51\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6841849\" class=\"form-group\" id=\"fld_6841849_2-wrap\">\r\n\t<label id=\"fld_6841849Label\" for=\"fld_6841849_2\" class=\"control-label\">Couro Cabeludo <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1227697\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Seco\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1227697\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1227697]\"\n                                value=\"Seco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Seco\"\n                            >\n                    Seco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1414270\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Oleoso\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1414270\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1414270]\"\n                                value=\"Oleoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Oleoso\"\n                            >\n                    Oleoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1325605\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Caspa\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1325605\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1325605]\"\n                                value=\"Caspa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Caspa\"\n                            >\n                    Caspa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1099916\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Queda de cabelo\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1099916\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1099916]\"\n                                value=\"Queda de cabelo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Queda de cabelo\"\n                            >\n                    Queda de cabelo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1240555\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Cavo\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1240555\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1240555]\"\n                                value=\"Cavo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Cavo\"\n                            >\n                    Cavo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6841849_2_opt1982355\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6841849_2\" data-parsley-multiple=\"fld_6841849_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6841849\"\n                                id=\"fld_6841849_2_opt1982355\"\n                                class=\"fld_6841849_2 option-required\"\n                                name=\"fld_6841849[opt1982355]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6841849_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5947451_2\" data-field-id=\"fld_5947451_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_4421454_2\" data-field-id=\"fld_4421454_2\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7735289_2\" data-field-id=\"fld_7735289_2\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1241280_2\" data-field-id=\"fld_1241280_2\"><\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_437986_2\" data-field-id=\"fld_437986_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-52\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_688914\" class=\"form-group\" id=\"fld_688914_2-wrap\">\r\n\t<label id=\"fld_688914Label\" for=\"fld_688914_2\" class=\"control-label\">Outros <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1362941\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Problema de mem\u00f3ria\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1362941\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1362941]\"\n                                value=\"Problema de mem\u00f3ria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Problema de mem\u00f3ria\"\n                            >\n                    Problema de mem\u00f3ria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1737042\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Vertigens\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1737042\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1737042]\"\n                                value=\"Vertigens\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Vertigens\"\n                            >\n                    Vertigens                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1191725\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Tontura\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1191725\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1191725]\"\n                                value=\"Tontura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Tontura\"\n                            >\n                    Tontura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1805476\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Desmaio\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1805476\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1805476]\"\n                                value=\"Desmaio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Desmaio\"\n                            >\n                    Desmaio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1081099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Dores de cabe\u00e7a\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1081099\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1081099]\"\n                                value=\"Dores de cabe\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Dores de cabe\u00e7a\"\n                            >\n                    Dores de cabe\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1086357\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Problemas no sono\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1086357\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1086357]\"\n                                value=\"Problemas no sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Problemas no sono\"\n                            >\n                    Problemas no sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1480045\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Ansiedade\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1480045\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1480045]\"\n                                value=\"Ansiedade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Ansiedade\"\n                            >\n                    Ansiedade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1683703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1683703\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1683703]\"\n                                value=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Altera\u00e7\u00f5es r\u00e1pidas de humor\"\n                            >\n                    Altera\u00e7\u00f5es r\u00e1pidas de humor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1752154\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Falta de apetite sexual\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1752154\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1752154]\"\n                                value=\"Falta de apetite sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Falta de apetite sexual\"\n                            >\n                    Falta de apetite sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1463952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Melancolia ou depress\u00e3o\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1463952\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1463952]\"\n                                value=\"Melancolia ou depress\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Melancolia ou depress\u00e3o\"\n                            >\n                    Melancolia ou depress\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt2022132\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Pensamento obsessivo\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt2022132\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt2022132]\"\n                                value=\"Pensamento obsessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Pensamento obsessivo\"\n                            >\n                    Pensamento obsessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1621008\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Febres\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1621008\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1621008]\"\n                                value=\"Febres\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Febres\"\n                            >\n                    Febres                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1282989\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Calafrios\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1282989\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1282989]\"\n                                value=\"Calafrios\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Calafrios\"\n                            >\n                    Calafrios                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt2049076\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Fadiga\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt2049076\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt2049076]\"\n                                value=\"Fadiga\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Fadiga\"\n                            >\n                    Fadiga                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt2064014\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Fraqueza\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt2064014\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt2064014]\"\n                                value=\"Fraqueza\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Fraqueza\"\n                            >\n                    Fraqueza                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1778566\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Tremores\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1778566\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1778566]\"\n                                value=\"Tremores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Tremores\"\n                            >\n                    Tremores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1794012\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Dor nevr\u00e1lgica\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1794012\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1794012]\"\n                                value=\"Dor nevr\u00e1lgica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Dor nevr\u00e1lgica\"\n                            >\n                    Dor nevr\u00e1lgica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1596238\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Perda de peso\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1596238\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1596238]\"\n                                value=\"Perda de peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Perda de peso\"\n                            >\n                    Perda de peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1591715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Ganho de peso\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1591715\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1591715]\"\n                                value=\"Ganho de peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Ganho de peso\"\n                            >\n                    Ganho de peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1816838\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Desconforto em ambientes \u00famidos ou mofados\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1816838\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1816838]\"\n                                value=\"Desconforto em ambientes \u00famidos ou mofados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Desconforto em ambientes \u00famidos ou mofados\"\n                            >\n                    Desconforto em ambientes \u00famidos ou mofados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1546917\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1546917\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1546917]\"\n                                value=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes\"\n                            >\n                    Sensibilidade ao tabaco, odores qu\u00edmicos ou perfumes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_688914_2_opt1641949\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_688914_2\" data-parsley-multiple=\"fld_688914_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_688914\"\n                                id=\"fld_688914_2_opt1641949\"\n                                class=\"fld_688914_2 option-required\"\n                                name=\"fld_688914[opt1641949]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_688914_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_2791673\" class=\"form-group\" id=\"fld_2791673_2-wrap\">\r\n\t<label id=\"fld_2791673Label\" for=\"fld_2791673_2\" class=\"control-label\">Situa\u00e7\u00e3o n\u00e3o citada anteriormente<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2791673\" value=\"\" data-field=\"fld_2791673\" class=\"form-control\" id=\"fld_2791673_2\" rows=\"4\"    aria-labelledby=\"fld_2791673Label\" aria-describedby=\"fld_2791673Caption\" ><\/textarea>\n\t\t<span id=\"fld_2791673Caption\" class=\"help-block\">Que voc\u00ea ache relevante mencionar<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-53\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_163810\" class=\"form-group\" id=\"fld_163810_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_163810\" id=\"fld_163810_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_163810\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_163810\" id=\"fld_163810_2_btn\" value=\"\" data-field=\"fld_163810\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6865005\" class=\"form-group\" id=\"fld_6865005_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_6865005\" id=\"fld_6865005_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_6865005\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_6865005\" id=\"fld_6865005_2_btn\" value=\"\" data-field=\"fld_6865005\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8261448\" class=\"form-group\" id=\"fld_8261448_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_8261448\" id=\"fld_8261448_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_8261448\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_8261448\" id=\"fld_8261448_2_btn\" value=\"\" data-field=\"fld_8261448\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_10\" data-formpage=\"10\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_10\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-54\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_495397\" class=\"form-group\" id=\"fld_495397_2-wrap\">\r\n\t<label id=\"fld_495397Label\" for=\"fld_495397_2\" class=\"control-label\">Como voc\u00ea v\u00ea seu corpo? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1341765\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Normal\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1341765\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1341765]\"\n                                value=\"Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Normal\"\n                            >\n                    Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1267692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Delgado\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1267692\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1267692]\"\n                                value=\"Delgado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Delgado\"\n                            >\n                    Delgado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1411452\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Gordinho\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1411452\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1411452]\"\n                                value=\"Gordinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Gordinho\"\n                            >\n                    Gordinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1758425\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Abaixo do peso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1758425\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1758425]\"\n                                value=\"Abaixo do peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Abaixo do peso\"\n                            >\n                    Abaixo do peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1445429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Acima do peso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1445429\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1445429]\"\n                                value=\"Acima do peso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Acima do peso\"\n                            >\n                    Acima do peso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1778788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Estatura alta\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1778788\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1778788]\"\n                                value=\"Estatura alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Estatura alta\"\n                            >\n                    Estatura alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1736760\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Estatura m\u00e9dia\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1736760\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1736760]\"\n                                value=\"Estatura m\u00e9dia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Estatura m\u00e9dia\"\n                            >\n                    Estatura m\u00e9dia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1544298\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Estatura baixa\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1544298\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1544298]\"\n                                value=\"Estatura baixa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Estatura baixa\"\n                            >\n                    Estatura baixa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1845746\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Ombros estreitos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1845746\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1845746]\"\n                                value=\"Ombros estreitos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Ombros estreitos\"\n                            >\n                    Ombros estreitos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1633499\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Ombros largos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1633499\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1633499]\"\n                                value=\"Ombros largos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Ombros largos\"\n                            >\n                    Ombros largos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1802465\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Bra\u00e7os finos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1802465\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1802465]\"\n                                value=\"Bra\u00e7os finos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Bra\u00e7os finos\"\n                            >\n                    Bra\u00e7os finos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1818336\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Bra\u00e7os fl\u00e1cidos\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1818336\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1818336]\"\n                                value=\"Bra\u00e7os fl\u00e1cidos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Bra\u00e7os fl\u00e1cidos\"\n                            >\n                    Bra\u00e7os fl\u00e1cidos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1682496\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Abdome liso\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1682496\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1682496]\"\n                                value=\"Abdome liso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Abdome liso\"\n                            >\n                    Abdome liso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1106913\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Abdome Fl\u00e1cido\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1106913\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1106913]\"\n                                value=\"Abdome Fl\u00e1cido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Abdome Fl\u00e1cido\"\n                            >\n                    Abdome Fl\u00e1cido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1628440\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Quadril estreito\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1628440\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1628440]\"\n                                value=\"Quadril estreito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Quadril estreito\"\n                            >\n                    Quadril estreito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1772345\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Quadril largo\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1772345\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1772345]\"\n                                value=\"Quadril largo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Quadril largo\"\n                            >\n                    Quadril largo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1936769\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1degas grandes\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1936769\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1936769]\"\n                                value=\"N\u00e1degas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"N\u00e1degas grandes\"\n                            >\n                    N\u00e1degas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1216840\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e1degas pequenas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1216840\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1216840]\"\n                                value=\"N\u00e1degas pequenas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"N\u00e1degas pequenas\"\n                            >\n                    N\u00e1degas pequenas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1880535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Coxas torneadas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1880535\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1880535]\"\n                                value=\"Coxas torneadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Coxas torneadas\"\n                            >\n                    Coxas torneadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1901591\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Coxas fl\u00e1cidas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1901591\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1901591]\"\n                                value=\"Coxas fl\u00e1cidas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Coxas fl\u00e1cidas\"\n                            >\n                    Coxas fl\u00e1cidas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1206394\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Pernas finas\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1206394\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1206394]\"\n                                value=\"Pernas finas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Pernas finas\"\n                            >\n                    Pernas finas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt2080349\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Corpo em forma de ampulheta\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt2080349\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt2080349]\"\n                                value=\"Corpo em forma de ampulheta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Corpo em forma de ampulheta\"\n                            >\n                    Corpo em forma de ampulheta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1198396\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Corpo em forma de pera\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1198396\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1198396]\"\n                                value=\"Corpo em forma de pera\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Corpo em forma de pera\"\n                            >\n                    Corpo em forma de pera                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_495397_2_opt1586651\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_495397_2\" data-parsley-multiple=\"fld_495397_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_495397\"\n                                id=\"fld_495397_2_opt1586651\"\n                                class=\"fld_495397_2 option-required\"\n                                name=\"fld_495397[opt1586651]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_495397_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5184946_2\" data-field-id=\"fld_5184946_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6779368\" class=\"form-group\" id=\"fld_6779368_2-wrap\">\r\n\t<label id=\"fld_6779368Label\" for=\"fld_6779368_2\" class=\"control-label\">Como voc\u00ea v\u00ea seu rosto? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1913414\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Oval\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1913414\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1913414]\"\n                                value=\"Oval\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Oval\"\n                            >\n                    Oval                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt2070963\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Quadrado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt2070963\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt2070963]\"\n                                value=\"Quadrado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Quadrado\"\n                            >\n                    Quadrado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1418703\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Redondo\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1418703\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1418703]\"\n                                value=\"Redondo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Redondo\"\n                            >\n                    Redondo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1337689\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Testa alta\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1337689\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1337689]\"\n                                value=\"Testa alta\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Testa alta\"\n                            >\n                    Testa alta                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1424835\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Testa enrugada\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1424835\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1424835]\"\n                                value=\"Testa enrugada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Testa enrugada\"\n                            >\n                    Testa enrugada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1392540\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Orelhas normais\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1392540\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1392540]\"\n                                value=\"Orelhas normais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Orelhas normais\"\n                            >\n                    Orelhas normais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1571283\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Orelhas grandes\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1571283\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1571283]\"\n                                value=\"Orelhas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Orelhas grandes\"\n                            >\n                    Orelhas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt2053363\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Queixo recuado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt2053363\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt2053363]\"\n                                value=\"Queixo recuado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Queixo recuado\"\n                            >\n                    Queixo recuado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1918847\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Queixo quadrado\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1918847\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1918847]\"\n                                value=\"Queixo quadrado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Queixo quadrado\"\n                            >\n                    Queixo quadrado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1279022\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Bochechas normais\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1279022\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1279022]\"\n                                value=\"Bochechas normais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Bochechas normais\"\n                            >\n                    Bochechas normais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1514673\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Bochechas grandes\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1514673\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1514673]\"\n                                value=\"Bochechas grandes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Bochechas grandes\"\n                            >\n                    Bochechas grandes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1548620\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Forma de cora\u00e7\u00e3o\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1548620\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1548620]\"\n                                value=\"Forma de cora\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Forma de cora\u00e7\u00e3o\"\n                            >\n                    Forma de cora\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1462428\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Dorma de diamante\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1462428\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1462428]\"\n                                value=\"Dorma de diamante\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Dorma de diamante\"\n                            >\n                    Dorma de diamante                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6779368_2_opt1891411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6779368_2\" data-parsley-multiple=\"fld_6779368_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6779368\"\n                                id=\"fld_6779368_2_opt1891411\"\n                                class=\"fld_6779368_2 option-required\"\n                                name=\"fld_6779368[opt1891411]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6779368_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_9781446_2\" data-field-id=\"fld_9781446_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-55\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8989705\" class=\"form-group\" id=\"fld_8989705_2-wrap\">\r\n\t<label id=\"fld_8989705Label\" for=\"fld_8989705_2\" class=\"control-label\">Como voc\u00ea v\u00ea sua express\u00e3o facial? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1154354\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Feliz\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1154354\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1154354]\"\n                                value=\"Feliz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Feliz\"\n                            >\n                    Feliz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1709908\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Sorridente\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1709908\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1709908]\"\n                                value=\"Sorridente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Sorridente\"\n                            >\n                    Sorridente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1542907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Orgulhosa\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1542907\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1542907]\"\n                                value=\"Orgulhosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Orgulhosa\"\n                            >\n                    Orgulhosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt2011870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Assustada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt2011870\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt2011870]\"\n                                value=\"Assustada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Assustada\"\n                            >\n                    Assustada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1988412\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Feroz\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1988412\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1988412]\"\n                                value=\"Feroz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Feroz\"\n                            >\n                    Feroz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1616685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Raivosa\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1616685\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1616685]\"\n                                value=\"Raivosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Raivosa\"\n                            >\n                    Raivosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1992369\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Fria\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1992369\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1992369]\"\n                                value=\"Fria\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Fria\"\n                            >\n                    Fria                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt2060092\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Cansada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt2060092\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt2060092]\"\n                                value=\"Cansada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Cansada\"\n                            >\n                    Cansada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1268643\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Suspeita\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1268643\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1268643]\"\n                                value=\"Suspeita\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Suspeita\"\n                            >\n                    Suspeita                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1347771\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Preocupada\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1347771\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1347771]\"\n                                value=\"Preocupada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Preocupada\"\n                            >\n                    Preocupada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8989705_2_opt1194404\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8989705_2\" data-parsley-multiple=\"fld_8989705_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8989705\"\n                                id=\"fld_8989705_2_opt1194404\"\n                                class=\"fld_8989705_2 option-required\"\n                                name=\"fld_8989705[opt1194404]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8989705_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7632005_2\" data-field-id=\"fld_7632005_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9441006\" class=\"form-group\" id=\"fld_9441006_2-wrap\">\r\n<label id=\"fld_9441006Label\" for=\"fld_9441006_2\" class=\"control-label\">Qual a cor dos seus olhos? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Verde\" for=\"fld_9441006_2_opt1271878\"><input type=\"radio\" id=\"fld_9441006_2_opt1271878\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Verde\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Verde\" \/>\n\t\t\tVerde\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Azul\" for=\"fld_9441006_2_opt1399360\"><input type=\"radio\" id=\"fld_9441006_2_opt1399360\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Azul\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Azul\" \/>\n\t\t\tAzul\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Castanho claro\" for=\"fld_9441006_2_opt1928196\"><input type=\"radio\" id=\"fld_9441006_2_opt1928196\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Castanho claro\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Castanho claro\" \/>\n\t\t\tCastanho claro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Castanho escuro\" for=\"fld_9441006_2_opt1260479\"><input type=\"radio\" id=\"fld_9441006_2_opt1260479\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Castanho escuro\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Castanho escuro\" \/>\n\t\t\tCastanho escuro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Preto\" for=\"fld_9441006_2_opt1431839\"><input type=\"radio\" id=\"fld_9441006_2_opt1431839\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Preto\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Preto\" \/>\n\t\t\tPreto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Vermelho (Cores raras)\" for=\"fld_9441006_2_opt1631248\"><input type=\"radio\" id=\"fld_9441006_2_opt1631248\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Vermelho (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Vermelho (Cores raras)\" \/>\n\t\t\tVermelho (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Rosa (Cores raras)\" for=\"fld_9441006_2_opt1400799\"><input type=\"radio\" id=\"fld_9441006_2_opt1400799\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Rosa (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Rosa (Cores raras)\" \/>\n\t\t\tRosa (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Violeta (Cores raras)\" for=\"fld_9441006_2_opt1953019\"><input type=\"radio\" id=\"fld_9441006_2_opt1953019\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"Violeta (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"Violeta (Cores raras)\" \/>\n\t\t\tVioleta (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"\u00c2mbar (Cores raras)\" for=\"fld_9441006_2_opt1253226\"><input type=\"radio\" id=\"fld_9441006_2_opt1253226\" data-field=\"fld_9441006\" class=\"fld_9441006_2 option-required\" name=\"fld_9441006\" value=\"\u00c2mbar (Cores raras)\"   required=\"required\" data-radio-field=\"fld_9441006_2\" data-type=\"radio\" data-calc-value=\"\u00c2mbar (Cores raras)\" \/>\n\t\t\t\u00c2mbar (Cores raras)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF603020f491e20_2-row-56\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7468061\" class=\"form-group\" id=\"fld_7468061_2-wrap\">\r\n<label id=\"fld_7468061Label\" for=\"fld_7468061_2\" class=\"control-label\">Qual a cor natural do seu cabelo? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Preto\" for=\"fld_7468061_2_opt1691168\"><input type=\"radio\" id=\"fld_7468061_2_opt1691168\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Preto\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Preto\" \/>\n\t\t\tPreto\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Marrom\" for=\"fld_7468061_2_opt1814183\"><input type=\"radio\" id=\"fld_7468061_2_opt1814183\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Marrom\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Marrom\" \/>\n\t\t\tMarrom\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Loiro\" for=\"fld_7468061_2_opt1852592\"><input type=\"radio\" id=\"fld_7468061_2_opt1852592\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Loiro\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Loiro\" \/>\n\t\t\tLoiro\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Ruivo\" for=\"fld_7468061_2_opt1163534\"><input type=\"radio\" id=\"fld_7468061_2_opt1163534\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Ruivo\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Ruivo\" \/>\n\t\t\tRuivo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Cinza\" for=\"fld_7468061_2_opt1227501\"><input type=\"radio\" id=\"fld_7468061_2_opt1227501\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Cinza\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Cinza\" \/>\n\t\t\tCinza\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Branco (albino)\" for=\"fld_7468061_2_opt1278283\"><input type=\"radio\" id=\"fld_7468061_2_opt1278283\" data-field=\"fld_7468061\" class=\"fld_7468061_2 option-required\" name=\"fld_7468061\" value=\"Branco (albino)\"   required=\"required\" data-radio-field=\"fld_7468061_2\" data-type=\"radio\" data-calc-value=\"Branco (albino)\" \/>\n\t\t\tBranco (albino)\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF603020f491e20_2-row-57\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_1382587\" class=\"form-group\" id=\"fld_1382587_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_1382587\" id=\"fld_1382587_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_1382587\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_1382587\" id=\"fld_1382587_2_btn\" value=\"\" data-field=\"fld_1382587\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_9153598\" class=\"form-group\" id=\"fld_9153598_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-next\" type=\"button\" name=\"fld_9153598\" id=\"fld_9153598_2\" value=\"P\u00e1gina Seguinte\" data-field=\"fld_9153598\" data-page=\"next\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_9153598\" id=\"fld_9153598_2_btn\" value=\"\" data-field=\"fld_9153598\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_2883934\" class=\"form-group\" id=\"fld_2883934_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_2883934\" id=\"fld_2883934_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_2883934\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_2883934\" id=\"fld_2883934_2_btn\" value=\"\" data-field=\"fld_2883934\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><\/div><\/div><div id=\"form_page_2_pg_11\" data-formpage=\"11\" role=\"region\" aria-labelledby=\"breadcrumb_2_pg_11\" aria-hidden=\"true\" class=\"caldera-form-page\" style=\"display:none;\"><div id=\"CF603020f491e20_2-row-58\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_9768910\" class=\"form-group\" id=\"fld_9768910_2-wrap\">\r\n\t<label id=\"fld_9768910Label\" for=\"fld_9768910_2\" class=\"control-label\">Descreva seu car\u00e1ter <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1667960\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Afetuso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1667960\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1667960]\"\n                                value=\"Afetuso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Afetuso\"\n                            >\n                    Afetuso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1142992\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Alegre\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1142992\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1142992]\"\n                                value=\"Alegre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Alegre\"\n                            >\n                    Alegre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1923804\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Ambicioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1923804\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1923804]\"\n                                value=\"Ambicioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Ambicioso\"\n                            >\n                    Ambicioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1498788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Ansioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1498788\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1498788]\"\n                                value=\"Ansioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Ansioso\"\n                            >\n                    Ansioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1266952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Argumentativo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1266952\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1266952]\"\n                                value=\"Argumentativo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Argumentativo\"\n                            >\n                    Argumentativo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1633100\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Bobo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1633100\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1633100]\"\n                                value=\"Bobo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Bobo\"\n                            >\n                    Bobo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1799730\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Briguento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1799730\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1799730]\"\n                                value=\"Briguento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Briguento\"\n                            >\n                    Briguento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1592225\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Cantor\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1592225\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1592225]\"\n                                value=\"Cantor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Cantor\"\n                            >\n                    Cantor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1200981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Caprichoso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1200981\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1200981]\"\n                                value=\"Caprichoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Caprichoso\"\n                            >\n                    Caprichoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1650360\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Ciumento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1650360\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1650360]\"\n                                value=\"Ciumento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Ciumento\"\n                            >\n                    Ciumento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1648755\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Compulsivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1648755\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1648755]\"\n                                value=\"Compulsivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Compulsivo\"\n                            >\n                    Compulsivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1514495\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Confuso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1514495\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1514495]\"\n                                value=\"Confuso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Confuso\"\n                            >\n                    Confuso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1665475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Desanimado\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1665475\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1665475]\"\n                                value=\"Desanimado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Desanimado\"\n                            >\n                    Desanimado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt2010409\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Destrutivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt2010409\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt2010409]\"\n                                value=\"Destrutivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Destrutivo\"\n                            >\n                    Destrutivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1260129\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Distraido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1260129\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1260129]\"\n                                value=\"Distraido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Distraido\"\n                            >\n                    Distraido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1401824\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Ditatorial\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1401824\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1401824]\"\n                                value=\"Ditatorial\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Ditatorial\"\n                            >\n                    Ditatorial                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1491921\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Doce\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1491921\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1491921]\"\n                                value=\"Doce\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Doce\"\n                            >\n                    Doce                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1479011\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Dominador\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1479011\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1479011]\"\n                                value=\"Dominador\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Dominador\"\n                            >\n                    Dominador                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1415494\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Exigente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1415494\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1415494]\"\n                                value=\"Exigente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Exigente\"\n                            >\n                    Exigente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1986502\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Fantasioso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1986502\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1986502]\"\n                                value=\"Fantasioso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Fantasioso\"\n                            >\n                    Fantasioso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1224693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Feliz\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1224693\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1224693]\"\n                                value=\"Feliz\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Feliz\"\n                            >\n                    Feliz                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1749307\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Filos\u00f3fico\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1749307\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1749307]\"\n                                value=\"Filos\u00f3fico\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Filos\u00f3fico\"\n                            >\n                    Filos\u00f3fico                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1936815\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Generoso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1936815\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1936815]\"\n                                value=\"Generoso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Generoso\"\n                            >\n                    Generoso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt2046031\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Gentil\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt2046031\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt2046031]\"\n                                value=\"Gentil\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Gentil\"\n                            >\n                    Gentil                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1410045\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Hiperativo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1410045\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1410045]\"\n                                value=\"Hiperativo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Hiperativo\"\n                            >\n                    Hiperativo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1543408\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Impaciente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1543408\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1543408]\"\n                                value=\"Impaciente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Impaciente\"\n                            >\n                    Impaciente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1576081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Impulsivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1576081\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1576081]\"\n                                value=\"Impulsivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Impulsivo\"\n                            >\n                    Impulsivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1659699\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Indiferente\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1659699\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1659699]\"\n                                value=\"Indiferente\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Indiferente\"\n                            >\n                    Indiferente                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1845939\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Insatisfeito\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1845939\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1845939]\"\n                                value=\"Insatisfeito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Insatisfeito\"\n                            >\n                    Insatisfeito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1565623\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Irritado\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1565623\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1565623]\"\n                                value=\"Irritado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Irritado\"\n                            >\n                    Irritado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1457241\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"L\u00edder\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1457241\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1457241]\"\n                                value=\"L\u00edder\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"L\u00edder\"\n                            >\n                    L\u00edder                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1418688\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Meticuloso\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1418688\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1418688]\"\n                                value=\"Meticuloso\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Meticuloso\"\n                            >\n                    Meticuloso                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1115289\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Paradoxal\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1115289\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1115289]\"\n                                value=\"Paradoxal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Paradoxal\"\n                            >\n                    Paradoxal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1230440\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Passivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1230440\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1230440]\"\n                                value=\"Passivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Passivo\"\n                            >\n                    Passivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1403429\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Rude\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1403429\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1403429]\"\n                                value=\"Rude\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Rude\"\n                            >\n                    Rude                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1267122\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Sedento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1267122\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1267122]\"\n                                value=\"Sedento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Sedento\"\n                            >\n                    Sedento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1428870\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"S\u00e9rio\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1428870\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1428870]\"\n                                value=\"S\u00e9rio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"S\u00e9rio\"\n                            >\n                    S\u00e9rio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1833381\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Tagarela\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1833381\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1833381]\"\n                                value=\"Tagarela\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Tagarela\"\n                            >\n                    Tagarela                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1264997\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"T\u00edmido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1264997\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1264997]\"\n                                value=\"T\u00edmido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"T\u00edmido\"\n                            >\n                    T\u00edmido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt2034489\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Triste\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt2034489\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt2034489]\"\n                                value=\"Triste\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Triste\"\n                            >\n                    Triste                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1915932\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"A vida pelo trabalho\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1915932\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1915932]\"\n                                value=\"A vida pelo trabalho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"A vida pelo trabalho\"\n                            >\n                    A vida pelo trabalho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1786557\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Aliviado pelo choro\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1786557\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1786557]\"\n                                value=\"Aliviado pelo choro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Aliviado pelo choro\"\n                            >\n                    Aliviado pelo choro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1198685\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Amante dos animais\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1198685\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1198685]\"\n                                value=\"Amante dos animais\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Amante dos animais\"\n                            >\n                    Amante dos animais                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1563818\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Aprendiz lento\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1563818\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1563818]\"\n                                value=\"Aprendiz lento\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Aprendiz lento\"\n                            >\n                    Aprendiz lento                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1273434\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"As l\u00e1grimas com a m\u00fasica\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1273434\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1273434]\"\n                                value=\"As l\u00e1grimas com a m\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"As l\u00e1grimas com a m\u00fasica\"\n                            >\n                    As l\u00e1grimas com a m\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1920506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Facilmente ofendido\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1920506\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1920506]\"\n                                value=\"Facilmente ofendido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Facilmente ofendido\"\n                            >\n                    Facilmente ofendido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1372972\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Gosta de estar s\u00f3\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1372972\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1372972]\"\n                                value=\"Gosta de estar s\u00f3\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Gosta de estar s\u00f3\"\n                            >\n                    Gosta de estar s\u00f3                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1843270\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Medo de morrer\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1843270\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1843270]\"\n                                value=\"Medo de morrer\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Medo de morrer\"\n                            >\n                    Medo de morrer                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1645860\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Medo de dentista\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1645860\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1645860]\"\n                                value=\"Medo de dentista\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Medo de dentista\"\n                            >\n                    Medo de dentista                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1290815\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Obcecado com a religi\u00e3o\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1290815\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1290815]\"\n                                value=\"Obcecado com a religi\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Obcecado com a religi\u00e3o\"\n                            >\n                    Obcecado com a religi\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1427690\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Pior no calor\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1427690\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1427690]\"\n                                value=\"Pior no calor\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Pior no calor\"\n                            >\n                    Pior no calor                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1591419\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Pior no tempo seco\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1591419\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1591419]\"\n                                value=\"Pior no tempo seco\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Pior no tempo seco\"\n                            >\n                    Pior no tempo seco                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1974093\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"R\u00e1pido em fazer as coisas\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1974093\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1974093]\"\n                                value=\"R\u00e1pido em fazer as coisas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"R\u00e1pido em fazer as coisas\"\n                            >\n                    R\u00e1pido em fazer as coisas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1655123\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Sens\u00edvel ao ru\u00eddo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1655123\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1655123]\"\n                                value=\"Sens\u00edvel ao ru\u00eddo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Sens\u00edvel ao ru\u00eddo\"\n                            >\n                    Sens\u00edvel ao ru\u00eddo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1341190\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Um valent\u00e3o\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1341190\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1341190]\"\n                                value=\"Um valent\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Um valent\u00e3o\"\n                            >\n                    Um valent\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1533346\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Uma pessoa ao ar livre\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1533346\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1533346]\"\n                                value=\"Uma pessoa ao ar livre\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Uma pessoa ao ar livre\"\n                            >\n                    Uma pessoa ao ar livre                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1998390\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Verbalmente abusivo\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1998390\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1998390]\"\n                                value=\"Verbalmente abusivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Verbalmente abusivo\"\n                            >\n                    Verbalmente abusivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_9768910_2_opt1895088\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_9768910_2\" data-parsley-multiple=\"fld_9768910_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_9768910\"\n                                id=\"fld_9768910_2_opt1895088\"\n                                class=\"fld_9768910_2 option-required\"\n                                name=\"fld_9768910[opt1895088]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_9768910_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_411163_2\" data-field-id=\"fld_411163_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3099297\" class=\"form-group\" id=\"fld_3099297_2-wrap\">\r\n\t<label id=\"fld_3099297Label\" for=\"fld_3099297_2\" class=\"control-label\">O que ou quem voc\u00ea n\u00e3o gosta? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1901180\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Marido\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1901180\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1901180]\"\n                                value=\"Marido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Marido\"\n                            >\n                    Marido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1420068\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Esposo(a)\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1420068\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1420068]\"\n                                value=\"Esposo(a)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Esposo(a)\"\n                            >\n                    Esposo(a)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1989907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Filhos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1989907\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1989907]\"\n                                value=\"Filhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Filhos\"\n                            >\n                    Filhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1969583\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Amigos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1969583\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1969583]\"\n                                value=\"Amigos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Amigos\"\n                            >\n                    Amigos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1238716\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Estranhos\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1238716\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1238716]\"\n                                value=\"Estranhos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Estranhos\"\n                            >\n                    Estranhos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1718857\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Um membro da fam\u00edlia\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1718857\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1718857]\"\n                                value=\"Um membro da fam\u00edlia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Um membro da fam\u00edlia\"\n                            >\n                    Um membro da fam\u00edlia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1204141\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Empresa\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1204141\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1204141]\"\n                                value=\"Empresa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Empresa\"\n                            >\n                    Empresa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt2079215\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Trabalho escrito\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt2079215\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt2079215]\"\n                                value=\"Trabalho escrito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Trabalho escrito\"\n                            >\n                    Trabalho escrito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1462652\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Exerc\u00edcio\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1462652\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1462652]\"\n                                value=\"Exerc\u00edcio\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Exerc\u00edcio\"\n                            >\n                    Exerc\u00edcio                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1252296\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Exerc\u00edcio mental\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1252296\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1252296]\"\n                                value=\"Exerc\u00edcio mental\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Exerc\u00edcio mental\"\n                            >\n                    Exerc\u00edcio mental                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1297993\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"M\u00fasica\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1297993\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1297993]\"\n                                value=\"M\u00fasica\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"M\u00fasica\"\n                            >\n                    M\u00fasica                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1414568\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Ru\u00eddo\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1414568\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1414568]\"\n                                value=\"Ru\u00eddo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Ru\u00eddo\"\n                            >\n                    Ru\u00eddo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1961247\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Banho\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1961247\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1961247]\"\n                                value=\"Banho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Banho\"\n                            >\n                    Banho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt2070552\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Odores\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt2070552\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt2070552]\"\n                                value=\"Odores\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Odores\"\n                            >\n                    Odores                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1174423\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Luz solar\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1174423\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1174423]\"\n                                value=\"Luz solar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Luz solar\"\n                            >\n                    Luz solar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1902952\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Janelas fechadas\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1902952\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1902952]\"\n                                value=\"Janelas fechadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Janelas fechadas\"\n                            >\n                    Janelas fechadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1908593\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Ficar no interior\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1908593\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1908593]\"\n                                value=\"Ficar no interior\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Ficar no interior\"\n                            >\n                    Ficar no interior                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt2091788\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Roupas apertadas\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt2091788\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt2091788]\"\n                                value=\"Roupas apertadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Roupas apertadas\"\n                            >\n                    Roupas apertadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1443073\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Ser contrariado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1443073\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1443073]\"\n                                value=\"Ser contrariado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Ser contrariado\"\n                            >\n                    Ser contrariado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt2087621\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Ser consolado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt2087621\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt2087621]\"\n                                value=\"Ser consolado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Ser consolado\"\n                            >\n                    Ser consolado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1440500\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Estar errado\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1440500\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1440500]\"\n                                value=\"Estar errado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Estar errado\"\n                            >\n                    Estar errado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1174638\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es \"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1174638\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1174638]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es \"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es \"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                 <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3099297_2_opt1632862\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_3099297_2\" data-parsley-multiple=\"fld_3099297_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_3099297\"\n                                id=\"fld_3099297_2_opt1632862\"\n                                class=\"fld_3099297_2 option-required\"\n                                name=\"fld_3099297[opt1632862]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3099297_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_846866_2\" data-field-id=\"fld_846866_2\"><\/span><div data-field-wrapper=\"fld_5604272\" class=\"form-group\" id=\"fld_5604272_2-wrap\">\r\n\t<label id=\"fld_5604272Label\" for=\"fld_5604272_2\" class=\"control-label\">O que voc\u00ea mais teme? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1910465\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Afei\u00e7\u00e3o\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1910465\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1910465]\"\n                                value=\"Afei\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Afei\u00e7\u00e3o\"\n                            >\n                    Afei\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1080636\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Altura\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1080636\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1080636]\"\n                                value=\"Altura\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Altura\"\n                            >\n                    Altura                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt2011740\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Assaltantes\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt2011740\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt2011740]\"\n                                value=\"Assaltantes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Assaltantes\"\n                            >\n                    Assaltantes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1796603\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Cobras\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1796603\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1796603]\"\n                                value=\"Cobras\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Cobras\"\n                            >\n                    Cobras                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1973113\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Contradi\u00e7\u00e3o\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1973113\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1973113]\"\n                                value=\"Contradi\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Contradi\u00e7\u00e3o\"\n                            >\n                    Contradi\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1668994\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Dirigir\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1668994\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1668994]\"\n                                value=\"Dirigir\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Dirigir\"\n                            >\n                    Dirigir                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1539264\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Doen\u00e7a\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1539264\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1539264]\"\n                                value=\"Doen\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Doen\u00e7a\"\n                            >\n                    Doen\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1577692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Escuro\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1577692\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1577692]\"\n                                value=\"Escuro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Escuro\"\n                            >\n                    Escuro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1413731\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Estar sozinho\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1413731\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1413731]\"\n                                value=\"Estar sozinho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Estar sozinho\"\n                            >\n                    Estar sozinho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt2006274\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Falhar\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt2006274\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt2006274]\"\n                                value=\"Falhar\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Falhar\"\n                            >\n                    Falhar                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1917742\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Morte\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1917742\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1917742]\"\n                                value=\"Morte\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Morte\"\n                            >\n                    Morte                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1317228\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Multid\u00f5es\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1317228\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1317228]\"\n                                value=\"Multid\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Multid\u00f5es\"\n                            >\n                    Multid\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1262287\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Opini\u00e3o dos outros\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1262287\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1262287]\"\n                                value=\"Opini\u00e3o dos outros\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Opini\u00e3o dos outros\"\n                            >\n                    Opini\u00e3o dos outros                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1887475\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Ser tocado\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1887475\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1887475]\"\n                                value=\"Ser tocado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Ser tocado\"\n                            >\n                    Ser tocado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1752389\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Trovoadas\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1752389\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1752389]\"\n                                value=\"Trovoadas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Trovoadas\"\n                            >\n                    Trovoadas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1562011\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1562011\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1562011]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5604272_2_opt1666762\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_5604272_2\" data-parsley-multiple=\"fld_5604272_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_5604272\"\n                                id=\"fld_5604272_2_opt1666762\"\n                                class=\"fld_5604272_2 option-required\"\n                                name=\"fld_5604272[opt1666762]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5604272_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5703829_2\" data-field-id=\"fld_5703829_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-59\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6042275\" class=\"form-group\" id=\"fld_6042275_2-wrap\">\r\n\t<label id=\"fld_6042275Label\" for=\"fld_6042275_2\" class=\"control-label\">Como \u00e9 o seu sono? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1892984\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Normal\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1892984\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1892984]\"\n                                value=\"Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Normal\"\n                            >\n                    Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1686638\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Profundo\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1686638\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1686638]\"\n                                value=\"Profundo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Profundo\"\n                            >\n                    Profundo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1790276\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Inquieto\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1790276\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1790276]\"\n                                value=\"Inquieto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Inquieto\"\n                            >\n                    Inquieto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1515578\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Interrompido\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1515578\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1515578]\"\n                                value=\"Interrompido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Interrompido\"\n                            >\n                    Interrompido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1644411\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Perturbado\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1644411\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1644411]\"\n                                value=\"Perturbado\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Perturbado\"\n                            >\n                    Perturbado                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1822189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Curto\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1822189\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1822189]\"\n                                value=\"Curto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Curto\"\n                            >\n                    Curto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1923201\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Ins\u00f4nia\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1923201\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1923201]\"\n                                value=\"Ins\u00f4nia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Ins\u00f4nia\"\n                            >\n                    Ins\u00f4nia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1719637\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Apneia do sono\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1719637\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1719637]\"\n                                value=\"Apneia do sono\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Apneia do sono\"\n                            >\n                    Apneia do sono                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt2039008\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Fica com sono em p\u00e9\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt2039008\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt2039008]\"\n                                value=\"Fica com sono em p\u00e9\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Fica com sono em p\u00e9\"\n                            >\n                    Fica com sono em p\u00e9                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1567532\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Mau humor quando acorda\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1567532\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1567532]\"\n                                value=\"Mau humor quando acorda\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Mau humor quando acorda\"\n                            >\n                    Mau humor quando acorda                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1760354\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Evita dormir sobre o lado direito da cama\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1760354\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1760354]\"\n                                value=\"Evita dormir sobre o lado direito da cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Evita dormir sobre o lado direito da cama\"\n                            >\n                    Evita dormir sobre o lado direito da cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1782487\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Evita dormir sobre o lado esquerdo da cama\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1782487\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1782487]\"\n                                value=\"Evita dormir sobre o lado esquerdo da cama\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Evita dormir sobre o lado esquerdo da cama\"\n                            >\n                    Evita dormir sobre o lado esquerdo da cama                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1144693\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Terrores noturnos\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1144693\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1144693]\"\n                                value=\"Terrores noturnos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Terrores noturnos\"\n                            >\n                    Terrores noturnos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_6042275_2_opt1975442\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_6042275_2\" data-parsley-multiple=\"fld_6042275_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_6042275\"\n                                id=\"fld_6042275_2_opt1975442\"\n                                class=\"fld_6042275_2 option-required\"\n                                name=\"fld_6042275[opt1975442]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_6042275_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1642058_2\" data-field-id=\"fld_1642058_2\"><\/span><\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_8328657\" class=\"form-group\" id=\"fld_8328657_2-wrap\">\r\n\t<label id=\"fld_8328657Label\" for=\"fld_8328657_2\" class=\"control-label\">Sintomas Emocionais <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt2072884\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Alucina\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt2072884\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt2072884]\"\n                                value=\"Alucina\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Alucina\u00e7\u00e3o\"\n                            >\n                    Alucina\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1768646\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Ansiedade\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1768646\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1768646]\"\n                                value=\"Ansiedade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Ansiedade\"\n                            >\n                    Ansiedade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1450071\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o a crian\u00e7as\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1450071\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1450071]\"\n                                value=\"Avers\u00e3o a crian\u00e7as\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Avers\u00e3o a crian\u00e7as\"\n                            >\n                    Avers\u00e3o a crian\u00e7as                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1946535\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o ao mental\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1946535\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1946535]\"\n                                value=\"Avers\u00e3o ao mental\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Avers\u00e3o ao mental\"\n                            >\n                    Avers\u00e3o ao mental                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1166827\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Avers\u00e3o ao trabalho\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1166827\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1166827]\"\n                                value=\"Avers\u00e3o ao trabalho\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Avers\u00e3o ao trabalho\"\n                            >\n                    Avers\u00e3o ao trabalho                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1072907\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Confus\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1072907\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1072907]\"\n                                value=\"Confus\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Confus\u00e3o\"\n                            >\n                    Confus\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1488446\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Cora\u00e7\u00e3o partido\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1488446\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1488446]\"\n                                value=\"Cora\u00e7\u00e3o partido\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Cora\u00e7\u00e3o partido\"\n                            >\n                    Cora\u00e7\u00e3o partido                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt2053478\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Depress\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt2053478\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt2053478]\"\n                                value=\"Depress\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Depress\u00e3o\"\n                            >\n                    Depress\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1781550\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Desejo de aten\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1781550\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1781550]\"\n                                value=\"Desejo de aten\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Desejo de aten\u00e7\u00e3o\"\n                            >\n                    Desejo de aten\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1226081\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de aprendizagem\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1226081\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1226081]\"\n                                value=\"Dificuldade de aprendizagem\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Dificuldade de aprendizagem\"\n                            >\n                    Dificuldade de aprendizagem                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1802287\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Falta de concentra\u00e7\u00e3o\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1802287\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1802287]\"\n                                value=\"Falta de concentra\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Falta de concentra\u00e7\u00e3o\"\n                            >\n                    Falta de concentra\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1699692\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Instabilidade emocional\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1699692\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1699692]\"\n                                value=\"Instabilidade emocional\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Instabilidade emocional\"\n                            >\n                    Instabilidade emocional                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1940065\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Manias ou TOC\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1940065\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1940065]\"\n                                value=\"Manias ou TOC\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Manias ou TOC\"\n                            >\n                    Manias ou TOC                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1693115\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Mem\u00f3ria fraca\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1693115\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1693115]\"\n                                value=\"Mem\u00f3ria fraca\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Mem\u00f3ria fraca\"\n                            >\n                    Mem\u00f3ria fraca                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1213400\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Raiva\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1213400\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1213400]\"\n                                value=\"Raiva\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Raiva\"\n                            >\n                    Raiva                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1596558\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Repuls\u00e3o para o sexo\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1596558\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1596558]\"\n                                value=\"Repuls\u00e3o para o sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Repuls\u00e3o para o sexo\"\n                            >\n                    Repuls\u00e3o para o sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1847615\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Tend\u00eancias suicidas\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1847615\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1847615]\"\n                                value=\"Tend\u00eancias suicidas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Tend\u00eancias suicidas\"\n                            >\n                    Tend\u00eancias suicidas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1210235\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1210235\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1210235]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8328657_2_opt1173020\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8328657_2\" data-parsley-multiple=\"fld_8328657_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8328657\"\n                                id=\"fld_8328657_2_opt1173020\"\n                                class=\"fld_8328657_2 option-required\"\n                                name=\"fld_8328657[opt1173020]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8328657_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_2102016_2\" data-field-id=\"fld_2102016_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-60\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8454960\" class=\"form-group\" id=\"fld_8454960_2-wrap\">\r\n\t<label id=\"fld_8454960Label\" for=\"fld_8454960_2\" class=\"control-label\">Sintomas sexuais <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1741551\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Apetite sexual excessivo\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1741551\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1741551]\"\n                                value=\"Apetite sexual excessivo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Apetite sexual excessivo\"\n                            >\n                    Apetite sexual excessivo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1970356\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Sexualmente insatisfeito\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1970356\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1970356]\"\n                                value=\"Sexualmente insatisfeito\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Sexualmente insatisfeito\"\n                            >\n                    Sexualmente insatisfeito                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1991164\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Coito dif\u00edcil\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1991164\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1991164]\"\n                                value=\"Coito dif\u00edcil\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Coito dif\u00edcil\"\n                            >\n                    Coito dif\u00edcil                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1697506\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Disfun\u00e7\u00e3o sexual\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1697506\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1697506]\"\n                                value=\"Disfun\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Disfun\u00e7\u00e3o sexual\"\n                            >\n                    Disfun\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1981920\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Repuls\u00e3o para sexo\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1981920\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1981920]\"\n                                value=\"Repuls\u00e3o para sexo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Repuls\u00e3o para sexo\"\n                            >\n                    Repuls\u00e3o para sexo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1315807\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1315807\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1315807]\"\n                                value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Nenhuma dessas op\u00e7\u00f5es\"\n                            >\n                    Nenhuma dessas op\u00e7\u00f5es                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_8454960_2_opt1647391\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_8454960_2\" data-parsley-multiple=\"fld_8454960_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_8454960\"\n                                id=\"fld_8454960_2_opt1647391\"\n                                class=\"fld_8454960_2 option-required\"\n                                name=\"fld_8454960[opt1647391]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_8454960_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7252825_2\" data-field-id=\"fld_7252825_2\"><\/span><\/div><\/div><div id=\"CF603020f491e20_2-row-61\"  class=\"row  last_row\"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_3088417\" class=\"form-group\" id=\"fld_3088417_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default cf-page-btn cf-page-btn-prev\" type=\"button\" name=\"fld_3088417\" id=\"fld_3088417_2\" value=\"P\u00e1gina Anterior\" data-field=\"fld_3088417\" data-page=\"prev\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_3088417\" id=\"fld_3088417_2_btn\" value=\"\" data-field=\"fld_3088417\"  \/>\n<\/div><div  class=\"col-sm-3 \"><\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6344075\" class=\"form-group\" id=\"fld_6344075_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"reset\" name=\"fld_6344075\" id=\"fld_6344075_2\" value=\"Limpar Formul\u00e1rio\" data-field=\"fld_6344075\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_6344075\" id=\"fld_6344075_2_btn\" value=\"\" data-field=\"fld_6344075\"  \/>\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8429954\" class=\"form-group\" id=\"fld_8429954_2-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_8429954\" id=\"fld_8429954_2\" value=\"Enviar Formul\u00e1rio\" data-field=\"fld_8429954\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_2\" type=\"hidden\" name=\"fld_8429954\" id=\"fld_8429954_2_btn\" value=\"\" data-field=\"fld_8429954\"  \/>\n<\/div><\/div><\/div><\/form>\r\n<\/div>\r\n<script type=\"text\/javascript\">\r\nif( typeof caldera_conditionals === \"undefined\" ){ var caldera_conditionals = {}; }caldera_conditionals.CF603020f491e20_2 = {\"fld_9442215_2\":{\"type\":\"show\",\"group\":{\"rw_skcba\":{\"cl_btaercssd\":{\"id\":\"cl_btaercssd\",\"field\":\"fld_1574495\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_skcba\",\"label\":\"Outro\"}}}},\"fld_7633772_2\":{\"type\":\"show\",\"group\":{\"rw_civeuhkrn\":{\"cl_hciyzdu\":{\"id\":\"cl_hciyzdu\",\"field\":\"fld_3473230\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_civeuhkrn\",\"label\":\"Outro\"}}}},\"fld_783295_2\":{\"type\":\"show\",\"group\":{\"rw_hsmptnce\":{\"cl_myntzmpf\":{\"id\":\"cl_myntzmpf\",\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_hsmptnce\",\"label\":\"Feminino\"}}}},\"fld_1576420_2\":{\"type\":\"show\",\"group\":{\"rw_xmrlvpc\":{\"cl_trghfltd\":{\"id\":\"cl_trghfltd\",\"field\":\"fld_8364991\",\"value\":\"Sim\",\"compare\":\"is\",\"parent\":\"rw_xmrlvpc\",\"label\":\"Sim\"}}}},\"fld_9024547_2\":{\"type\":\"show\",\"group\":{\"rw_inxbbckdd\":{\"cl_ytpjcjijxi\":{\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_inxbbckdd\",\"id\":\"cl_ytpjcjijxi\",\"label\":\"Feminino\"},\"cl_rqriwfefxw\":{\"field\":\"fld_8364991\",\"value\":\"Sim\",\"compare\":\"is\",\"parent\":\"rw_inxbbckdd\",\"id\":\"cl_rqriwfefxw\",\"label\":\"Sim\"}}}},\"fld_3885880_2\":{\"type\":\"show\",\"group\":{\"rw_mtzxthxaz\":{\"cl_yzyxua\":{\"id\":\"cl_yzyxua\",\"field\":\"fld_7159025\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_mtzxthxaz\",\"label\":\"Outro\"}}}},\"fld_6650295_2\":{\"type\":\"show\",\"group\":{\"rw_wgisij\":{\"cl_ctimru\":{\"id\":\"cl_ctimru\",\"field\":\"fld_6367522\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_wgisij\",\"label\":\"Outro\"}}}},\"fld_1530349_2\":{\"type\":\"hide\",\"group\":{\"rw_phnvnle\":{\"cl_bvhlrdd\":{\"id\":\"cl_bvhlrdd\",\"field\":\"fld_8952750\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_phnvnle\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_3043002_2\":{\"type\":\"hide\",\"group\":{\"rw_movycbfae\":{\"cl_gfhffyp\":{\"id\":\"cl_gfhffyp\",\"field\":\"fld_5652515\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_movycbfae\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_1619118_2\":{\"type\":\"hide\",\"group\":{\"rw_bqbajvdnuto\":{\"cl_heqptz\":{\"id\":\"cl_heqptz\",\"field\":\"fld_4659334\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_bqbajvdnuto\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_7494269_2\":{\"type\":\"show\",\"group\":{\"rw_pkquiuby\":{\"cl_nhsgxs\":{\"id\":\"cl_nhsgxs\",\"field\":\"fld_8514796\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_pkquiuby\",\"label\":\"Outro\"}}}},\"fld_6094755_2\":{\"type\":\"show\",\"group\":{\"rw_avmvvffhv\":{\"cl_oyljxzgj\":{\"id\":\"cl_oyljxzgj\",\"field\":\"fld_7513570\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_avmvvffhv\",\"label\":\"Outro\"}}}},\"fld_2575749_2\":{\"type\":\"hide\",\"group\":{\"rw_vllsbdzi\":{\"cl_lzltlmc\":{\"id\":\"cl_lzltlmc\",\"field\":\"fld_5873470\",\"value\":\"N\\u00e3o possuo\",\"compare\":\"is\",\"parent\":\"rw_vllsbdzi\",\"label\":\"N\\u00e3o possuo\"}}}},\"fld_7520435_2\":{\"type\":\"show\",\"group\":{\"rw_lvfuepfxv\":{\"cl_xelleremg\":{\"id\":\"cl_xelleremg\",\"field\":\"fld_5873470\",\"value\":\"Cigarro, charuto ou cachimbo\",\"compare\":\"is\",\"parent\":\"rw_lvfuepfxv\",\"label\":\"Cigarro, charuto ou cachimbo\"}}}},\"fld_977328_2\":{\"type\":\"show\",\"group\":{\"rw_qxfgbzkca\":{\"cl_pvchfosgg\":{\"id\":\"cl_pvchfosgg\",\"field\":\"fld_544334\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qxfgbzkca\",\"label\":\"Outro\"}}}},\"fld_2985878_2\":{\"type\":\"show\",\"group\":{\"rw_cixnmkuls\":{\"cl_gglonozmo\":{\"id\":\"cl_gglonozmo\",\"field\":\"fld_3226139\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_cixnmkuls\",\"label\":\"Outro\"}}}},\"fld_950222_2\":{\"type\":\"hide\",\"group\":{\"rw_dclqgp\":{\"cl_lfgftd\":{\"id\":\"cl_lfgftd\",\"field\":\"fld_6437431\",\"value\":\"N\\u00e3o, nunca ingeri\",\"compare\":\"is\",\"parent\":\"rw_dclqgp\",\"label\":\"N\\u00e3o, nunca ingeri\"}}}},\"fld_8312371_2\":{\"type\":\"show\",\"group\":{\"rw_gyrgxqsvw\":{\"cl_zehtok\":{\"id\":\"cl_zehtok\",\"field\":\"fld_5437915\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_gyrgxqsvw\",\"label\":\"Outro\"}}}},\"fld_804883_2\":{\"type\":\"show\",\"group\":{\"rw_buhqkcfq\":{\"cl_bhxtdzvtw\":{\"id\":\"cl_bhxtdzvtw\",\"field\":\"fld_2165263\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_buhqkcfq\",\"label\":\"Outro\"}}}},\"fld_821839_2\":{\"type\":\"show\",\"group\":{\"rw_mrbnokfco\":{\"cl_shdlwau\":{\"id\":\"cl_shdlwau\",\"field\":\"fld_3091293\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_mrbnokfco\",\"label\":\"Outro\"}}}},\"fld_3571860_2\":{\"type\":\"show\",\"group\":{\"rw_dwnpcthb\":{\"cl_twaeaii\":{\"id\":\"cl_twaeaii\",\"field\":\"fld_8297592\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_dwnpcthb\",\"label\":\"Outro\"}}}},\"fld_6470066_2\":{\"type\":\"show\",\"group\":{\"rw_vdtrsizis\":{\"cl_lqryqc\":{\"id\":\"cl_lqryqc\",\"field\":\"fld_8430632\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_vdtrsizis\",\"label\":\"Outro\"}}}},\"fld_2917925_2\":{\"type\":\"show\",\"group\":{\"rw_jmtfllzx\":{\"cl_drrkhrbul\":{\"id\":\"cl_drrkhrbul\",\"field\":\"fld_5600968\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_jmtfllzx\",\"label\":\"Outro\"}}}},\"fld_2304231_2\":{\"type\":\"show\",\"group\":{\"rw_bnmqzqq\":{\"cl_sqeed\":{\"id\":\"cl_sqeed\",\"field\":\"fld_2481233\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_bnmqzqq\",\"label\":\"Outro\"}}}},\"fld_6823998_2\":{\"type\":\"show\",\"group\":{\"rw_qdwencm\":{\"cl_oxxefeewel\":{\"id\":\"cl_oxxefeewel\",\"field\":\"fld_1996962\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qdwencm\",\"label\":\"Outro\"}}}},\"fld_2377312_2\":{\"type\":\"show\",\"group\":{\"rw_iwbduevvp\":{\"cl_ntbzwggh\":{\"id\":\"cl_ntbzwggh\",\"field\":\"fld_4596590\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_iwbduevvp\",\"label\":\"Outro\"}}}},\"fld_4147300_2\":{\"type\":\"show\",\"group\":{\"rw_wcxxmanq\":{\"cl_gqecchyabq\":{\"id\":\"cl_gqecchyabq\",\"field\":\"fld_7925824\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_wcxxmanq\",\"label\":\"Outro\"}}}},\"fld_6128378_2\":{\"type\":\"show\",\"group\":{\"rw_aizongnb\":{\"cl_wgxowlqnl\":{\"id\":\"cl_wgxowlqnl\",\"field\":\"fld_9756699\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_aizongnb\",\"label\":\"Outro\"}}}},\"fld_7039225_2\":{\"type\":\"show\",\"group\":{\"rw_llzjgsrke\":{\"cl_ictarpp\":{\"id\":\"cl_ictarpp\",\"field\":\"fld_5201432\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_llzjgsrke\",\"label\":\"Outro\"}}}},\"fld_224762_2\":{\"type\":\"show\",\"group\":{\"rw_qnjhoebz\":{\"cl_inuohkwyja\":{\"id\":\"cl_inuohkwyja\",\"field\":\"fld_1904780\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qnjhoebz\",\"label\":\"Outro\"}}}},\"fld_973027_2\":{\"type\":\"show\",\"group\":{\"rw_kmzhtcb\":{\"cl_hjyiwrbtmv\":{\"id\":\"cl_hjyiwrbtmv\",\"field\":\"fld_1633260\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kmzhtcb\",\"label\":\"Outro\"}}}},\"fld_7301016_2\":{\"type\":\"show\",\"group\":{\"rw_vbztskeqw\":{\"cl_osffexsm\":{\"id\":\"cl_osffexsm\",\"field\":\"fld_9478261\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_vbztskeqw\",\"label\":\"Outro\"}}}},\"fld_1855499_2\":{\"type\":\"show\",\"group\":{\"rw_sipaqxi\":{\"cl_pijvca\":{\"id\":\"cl_pijvca\",\"field\":\"fld_78322\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_sipaqxi\",\"label\":\"Outro\"}}}},\"fld_9690541_2\":{\"type\":\"show\",\"group\":{\"rw_kvzqryxbt\":{\"cl_onblzirm\":{\"id\":\"cl_onblzirm\",\"field\":\"fld_6108732\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kvzqryxbt\",\"label\":\"Outro\"}}}},\"fld_5947451_2\":{\"type\":\"show\",\"group\":{\"rw_asmzzneso\":{\"cl_qynoax\":{\"id\":\"cl_qynoax\",\"field\":\"fld_6841849\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_asmzzneso\",\"label\":\"Outro\"}}}},\"fld_4421454_2\":{\"type\":\"show\",\"group\":{\"rw_vzhicjq\":{\"cl_ukyqsqo\":{\"id\":\"cl_ukyqsqo\",\"field\":\"fld_2200576\",\"value\":\"Masculino\",\"compare\":\"is\",\"parent\":\"rw_vzhicjq\",\"label\":\"Masculino\"}}}},\"fld_7735289_2\":{\"type\":\"show\",\"group\":{\"rw_shcsrcvnm\":{\"cl_tqgmxo\":{\"id\":\"cl_tqgmxo\",\"field\":\"fld_4421454\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_shcsrcvnm\",\"label\":\"Outro\"}}}},\"fld_1241280_2\":{\"type\":\"show\",\"group\":{\"rw_hsmptnce\":{\"cl_myntzmpf\":{\"id\":\"cl_myntzmpf\",\"field\":\"fld_2200576\",\"value\":\"Feminino\",\"compare\":\"is\",\"parent\":\"rw_hsmptnce\",\"label\":\"Feminino\"}}}},\"fld_437986_2\":{\"type\":\"show\",\"group\":{\"rw_bgvepfpom\":{\"cl_rovgfand\":{\"id\":\"cl_rovgfand\",\"field\":\"fld_1241280\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_bgvepfpom\",\"label\":\"Outro\"}}}},\"fld_5184946_2\":{\"type\":\"show\",\"group\":{\"rw_iunrito\":{\"cl_mgilrbfj\":{\"id\":\"cl_mgilrbfj\",\"field\":\"fld_495397\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_iunrito\",\"label\":\"Outro\"}}}},\"fld_9781446_2\":{\"type\":\"show\",\"group\":{\"rw_qglhojev\":{\"cl_jccbi\":{\"id\":\"cl_jccbi\",\"field\":\"fld_6779368\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qglhojev\",\"label\":\"Outro\"}}}},\"fld_7632005_2\":{\"type\":\"show\",\"group\":{\"rw_dceejkqxcf\":{\"cl_kcosmqubng\":{\"id\":\"cl_kcosmqubng\",\"field\":\"fld_8989705\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_dceejkqxcf\",\"label\":\"Outro\"}}}},\"fld_411163_2\":{\"type\":\"show\",\"group\":{\"rw_kulqlzn\":{\"cl_yxmmokdlo\":{\"id\":\"cl_yxmmokdlo\",\"field\":\"fld_9768910\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_kulqlzn\",\"label\":\"Outro\"}}}},\"fld_846866_2\":{\"type\":\"show\",\"group\":{\"rw_arrgye\":{\"cl_qxxjxyyp\":{\"id\":\"cl_qxxjxyyp\",\"field\":\"fld_3099297\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_arrgye\",\"label\":\"Outro\"}}}},\"fld_5703829_2\":{\"type\":\"show\",\"group\":{\"rw_qfgsil\":{\"cl_ioopjmjnz\":{\"id\":\"cl_ioopjmjnz\",\"field\":\"fld_5604272\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_qfgsil\",\"label\":\"Outro\"}}}},\"fld_1642058_2\":{\"type\":\"show\",\"group\":{\"rw_werexpmda\":{\"cl_yxfpsu\":{\"id\":\"cl_yxfpsu\",\"field\":\"fld_6042275\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_werexpmda\",\"label\":\"Outro\"}}}},\"fld_2102016_2\":{\"type\":\"show\",\"group\":{\"rw_saqhee\":{\"cl_fmzpdib\":{\"id\":\"cl_fmzpdib\",\"field\":\"fld_8328657\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_saqhee\",\"label\":\"Outro\"}}}},\"fld_7252825_2\":{\"type\":\"show\",\"group\":{\"rw_aieriudw\":{\"cl_kdftnkg\":{\"id\":\"cl_kdftnkg\",\"field\":\"fld_8454960\",\"value\":\"Outro\",\"compare\":\"is\",\"parent\":\"rw_aieriudw\",\"label\":\"Outro\"}}}}};\r\n<\/script>\r\n<script type=\"text\/html\" id=\"conditional-fld_9442215_2-tmpl\">\r\n<div data-field-wrapper=\"fld_9442215\" class=\"form-group\" id=\"fld_9442215_2-wrap\">\r\n\t<label id=\"fld_9442215Label\" for=\"fld_9442215_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9442215\" class=\" form-control\" id=\"fld_9442215_2\" name=\"fld_9442215\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9442215Label\" aria-describedby=\"fld_9442215Caption\" >\t\t<span id=\"fld_9442215Caption\" class=\"help-block\">Informe qual estado civil<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7633772_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7633772\" class=\"form-group\" id=\"fld_7633772_2-wrap\">\r\n\t<label id=\"fld_7633772Label\" for=\"fld_7633772_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7633772\" class=\" form-control\" id=\"fld_7633772_2\" name=\"fld_7633772\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7633772Label\" aria-describedby=\"fld_7633772Caption\" >\t\t<span id=\"fld_7633772Caption\" class=\"help-block\">Informe qual escolaridade<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_783295_2-tmpl\">\r\n<div data-field-wrapper=\"fld_783295\" class=\"form-group\" id=\"fld_783295_2-wrap\">\r\n<label id=\"fld_783295Label\" for=\"fld_783295_2\" class=\"control-label\">Gestante <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Sim\" for=\"fld_783295_2_opt1721878\"><input type=\"radio\" id=\"fld_783295_2_opt1721878\" data-field=\"fld_783295\" class=\"fld_783295_2 option-required\" name=\"fld_783295\" value=\"Sim\"   required=\"required\" data-radio-field=\"fld_783295_2\" data-type=\"radio\" data-calc-value=\"Sim\" \/>\n\t\t\tSim\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"N\u00e3o\" for=\"fld_783295_2_opt1874201\"><input type=\"radio\" id=\"fld_783295_2_opt1874201\" data-field=\"fld_783295\" class=\"fld_783295_2 option-required\" name=\"fld_783295\" value=\"N\u00e3o\"   required=\"required\" data-radio-field=\"fld_783295_2\" data-type=\"radio\" data-calc-value=\"N\u00e3o\" \/>\n\t\t\tN\u00e3o\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1576420_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1576420\" class=\"form-group\" id=\"fld_1576420_2-wrap\">\r\n\t<label id=\"fld_1576420Label\" for=\"fld_1576420_2\" class=\"control-label\">Quantos <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"number\" data-field=\"fld_1576420\" class=\" form-control\" id=\"fld_1576420_2\" name=\"fld_1576420\" value=\"\" data-type=\"number\" data-parsley-type=\"number\" aria-required=\"true\"   aria-labelledby=\"fld_1576420Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9024547_2-tmpl\">\r\n<div data-field-wrapper=\"fld_9024547\" class=\"form-group\" id=\"fld_9024547_2-wrap\">\r\n\t<label id=\"fld_9024547Label\" for=\"fld_9024547_2\" class=\"control-label\">Descreva a gesta\u00e7\u00e3o(\u00f5es) e parto(s) <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9024547\" value=\"\" data-field=\"fld_9024547\" class=\"form-control\" id=\"fld_9024547_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_9024547Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3885880_2-tmpl\">\r\n<div data-field-wrapper=\"fld_3885880\" class=\"form-group\" id=\"fld_3885880_2-wrap\">\r\n\t<label id=\"fld_3885880Label\" for=\"fld_3885880_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_3885880\" class=\" form-control\" id=\"fld_3885880_2\" name=\"fld_3885880\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_3885880Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6650295_2-tmpl\">\r\n<div data-field-wrapper=\"fld_6650295\" class=\"form-group\" id=\"fld_6650295_2-wrap\">\r\n\t<label id=\"fld_6650295Label\" for=\"fld_6650295_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6650295\" class=\" form-control\" id=\"fld_6650295_2\" name=\"fld_6650295\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6650295Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1530349_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1530349\" class=\"form-group\" id=\"fld_1530349_2-wrap\">\r\n\t<label id=\"fld_1530349Label\" for=\"fld_1530349_2\" class=\"control-label\">Complementar <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1530349\" class=\" form-control\" id=\"fld_1530349_2\" name=\"fld_1530349\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1530349Label\" aria-describedby=\"fld_1530349Caption\" >\t\t<span id=\"fld_1530349Caption\" class=\"help-block\">Ex : Se possui obtura\u00e7\u00f5es, quantas? Se possui pr\u00f3tese ou membros artificiais, qual?<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3043002_2-tmpl\">\r\n<div data-field-wrapper=\"fld_3043002\" class=\"form-group\" id=\"fld_3043002_2-wrap\">\r\n\t<label id=\"fld_3043002Label\" for=\"fld_3043002_2\" class=\"control-label\">Descreva o(s) hist\u00f3rico(s) m\u00e9dico(s) marcado(s) acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3043002\" value=\"\" data-field=\"fld_3043002\" class=\"form-control\" id=\"fld_3043002_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_3043002Label\" aria-describedby=\"fld_3043002Caption\" ><\/textarea>\n\t\t<span id=\"fld_3043002Caption\" class=\"help-block\">Motivo, m\u00eas e ano, tempo de interna\u00e7\u00e3o, etc.<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1619118_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1619118\" class=\"form-group\" id=\"fld_1619118_2-wrap\">\r\n\t<label id=\"fld_1619118Label\" for=\"fld_1619118_2\" class=\"control-label\">Fale sobre as alergias marcadas acima <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1619118\" value=\"\" data-field=\"fld_1619118\" class=\"form-control\" id=\"fld_1619118_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_1619118Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7494269_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7494269\" class=\"form-group\" id=\"fld_7494269_2-wrap\">\r\n\t<label id=\"fld_7494269Label\" for=\"fld_7494269_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7494269\" class=\" form-control\" id=\"fld_7494269_2\" name=\"fld_7494269\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7494269Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6094755_2-tmpl\">\r\n<div data-field-wrapper=\"fld_6094755\" class=\"form-group\" id=\"fld_6094755_2-wrap\">\r\n\t<label id=\"fld_6094755Label\" for=\"fld_6094755_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6094755\" class=\" form-control\" id=\"fld_6094755_2\" name=\"fld_6094755\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6094755Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2575749_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2575749\" class=\"form-group\" id=\"fld_2575749_2-wrap\">\r\n\t<label id=\"fld_2575749Label\" for=\"fld_2575749_2\" class=\"control-label\">Quais? Tem inten\u00e7\u00e3o de parar o uso? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2575749\" value=\"\" data-field=\"fld_2575749\" class=\"form-control\" id=\"fld_2575749_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2575749Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7520435_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7520435\" class=\"form-group\" id=\"fld_7520435_2-wrap\">\r\n\t<label id=\"fld_7520435Label\" for=\"fld_7520435_2\" class=\"control-label\">Quantos vezes ao dia fuma? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7520435\" value=\"\" data-field=\"fld_7520435\" class=\"form-control\" id=\"fld_7520435_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7520435Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_977328_2-tmpl\">\r\n<div data-field-wrapper=\"fld_977328\" class=\"form-group\" id=\"fld_977328_2-wrap\">\r\n\t<label id=\"fld_977328Label\" for=\"fld_977328_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_977328\" class=\" form-control\" id=\"fld_977328_2\" name=\"fld_977328\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_977328Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2985878_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2985878\" class=\"form-group\" id=\"fld_2985878_2-wrap\">\r\n\t<label id=\"fld_2985878Label\" for=\"fld_2985878_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2985878\" class=\" form-control\" id=\"fld_2985878_2\" name=\"fld_2985878\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2985878Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_950222_2-tmpl\">\r\n<div data-field-wrapper=\"fld_950222\" class=\"form-group\" id=\"fld_950222_2-wrap\">\r\n\t<label id=\"fld_950222Label\" for=\"fld_950222_2\" class=\"control-label\">Descreva? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_950222\" value=\"\" data-field=\"fld_950222\" class=\"form-control\" id=\"fld_950222_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_950222Label\" aria-describedby=\"fld_950222Caption\" ><\/textarea>\n\t\t<span id=\"fld_950222Caption\" class=\"help-block\">Qual bebida e quantas doses ou a quanto tempo parou<\/span>\r\n\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_8312371_2-tmpl\">\r\n<div data-field-wrapper=\"fld_8312371\" class=\"form-group\" id=\"fld_8312371_2-wrap\">\r\n\t<label id=\"fld_8312371Label\" for=\"fld_8312371_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_8312371\" class=\" form-control\" id=\"fld_8312371_2\" name=\"fld_8312371\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_8312371Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_804883_2-tmpl\">\r\n<div data-field-wrapper=\"fld_804883\" class=\"form-group\" id=\"fld_804883_2-wrap\">\r\n\t<label id=\"fld_804883Label\" for=\"fld_804883_2\" class=\"control-label\">Descreva <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_804883\" value=\"\" data-field=\"fld_804883\" class=\"form-control\" id=\"fld_804883_2\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_804883Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_821839_2-tmpl\">\r\n<div data-field-wrapper=\"fld_821839\" class=\"form-group\" id=\"fld_821839_2-wrap\">\r\n\t<label id=\"fld_821839Label\" for=\"fld_821839_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_821839\" class=\" form-control\" id=\"fld_821839_2\" name=\"fld_821839\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_821839Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_3571860_2-tmpl\">\r\n<div data-field-wrapper=\"fld_3571860\" class=\"form-group\" id=\"fld_3571860_2-wrap\">\r\n\t<label id=\"fld_3571860Label\" for=\"fld_3571860_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_3571860\" class=\" form-control\" id=\"fld_3571860_2\" name=\"fld_3571860\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_3571860Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6470066_2-tmpl\">\r\n<div data-field-wrapper=\"fld_6470066\" class=\"form-group\" id=\"fld_6470066_2-wrap\">\r\n\t<label id=\"fld_6470066Label\" for=\"fld_6470066_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6470066\" class=\" form-control\" id=\"fld_6470066_2\" name=\"fld_6470066\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6470066Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2917925_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2917925\" class=\"form-group\" id=\"fld_2917925_2-wrap\">\r\n\t<label id=\"fld_2917925Label\" for=\"fld_2917925_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2917925\" class=\" form-control\" id=\"fld_2917925_2\" name=\"fld_2917925\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2917925Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2304231_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2304231\" class=\"form-group\" id=\"fld_2304231_2-wrap\">\r\n\t<label id=\"fld_2304231Label\" for=\"fld_2304231_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2304231\" class=\" form-control\" id=\"fld_2304231_2\" name=\"fld_2304231\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2304231Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6823998_2-tmpl\">\r\n<div data-field-wrapper=\"fld_6823998\" class=\"form-group\" id=\"fld_6823998_2-wrap\">\r\n\t<label id=\"fld_6823998Label\" for=\"fld_6823998_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6823998\" class=\" form-control\" id=\"fld_6823998_2\" name=\"fld_6823998\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6823998Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2377312_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2377312\" class=\"form-group\" id=\"fld_2377312_2-wrap\">\r\n\t<label id=\"fld_2377312Label\" for=\"fld_2377312_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2377312\" class=\" form-control\" id=\"fld_2377312_2\" name=\"fld_2377312\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2377312Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_4147300_2-tmpl\">\r\n<div data-field-wrapper=\"fld_4147300\" class=\"form-group\" id=\"fld_4147300_2-wrap\">\r\n\t<label id=\"fld_4147300Label\" for=\"fld_4147300_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_4147300\" class=\" form-control\" id=\"fld_4147300_2\" name=\"fld_4147300\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4147300Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_6128378_2-tmpl\">\r\n<div data-field-wrapper=\"fld_6128378\" class=\"form-group\" id=\"fld_6128378_2-wrap\">\r\n\t<label id=\"fld_6128378Label\" for=\"fld_6128378_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_6128378\" class=\" form-control\" id=\"fld_6128378_2\" name=\"fld_6128378\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6128378Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7039225_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7039225\" class=\"form-group\" id=\"fld_7039225_2-wrap\">\r\n\t<label id=\"fld_7039225Label\" for=\"fld_7039225_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7039225\" class=\" form-control\" id=\"fld_7039225_2\" name=\"fld_7039225\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7039225Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_224762_2-tmpl\">\r\n<div data-field-wrapper=\"fld_224762\" class=\"form-group\" id=\"fld_224762_2-wrap\">\r\n\t<label id=\"fld_224762Label\" for=\"fld_224762_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_224762\" class=\" form-control\" id=\"fld_224762_2\" name=\"fld_224762\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_224762Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_973027_2-tmpl\">\r\n<div data-field-wrapper=\"fld_973027\" class=\"form-group\" id=\"fld_973027_2-wrap\">\r\n\t<label id=\"fld_973027Label\" for=\"fld_973027_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_973027\" class=\" form-control\" id=\"fld_973027_2\" name=\"fld_973027\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_973027Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7301016_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7301016\" class=\"form-group\" id=\"fld_7301016_2-wrap\">\r\n\t<label id=\"fld_7301016Label\" for=\"fld_7301016_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7301016\" class=\" form-control\" id=\"fld_7301016_2\" name=\"fld_7301016\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7301016Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1855499_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1855499\" class=\"form-group\" id=\"fld_1855499_2-wrap\">\r\n\t<label id=\"fld_1855499Label\" for=\"fld_1855499_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1855499\" class=\" form-control\" id=\"fld_1855499_2\" name=\"fld_1855499\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1855499Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9690541_2-tmpl\">\r\n<div data-field-wrapper=\"fld_9690541\" class=\"form-group\" id=\"fld_9690541_2-wrap\">\r\n\t<label id=\"fld_9690541Label\" for=\"fld_9690541_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9690541\" class=\" form-control\" id=\"fld_9690541_2\" name=\"fld_9690541\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9690541Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5947451_2-tmpl\">\r\n<div data-field-wrapper=\"fld_5947451\" class=\"form-group\" id=\"fld_5947451_2-wrap\">\r\n\t<label id=\"fld_5947451Label\" for=\"fld_5947451_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5947451\" class=\" form-control\" id=\"fld_5947451_2\" name=\"fld_5947451\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5947451Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_4421454_2-tmpl\">\r\n<div data-field-wrapper=\"fld_4421454\" class=\"form-group\" id=\"fld_4421454_2-wrap\">\r\n\t<label id=\"fld_4421454Label\" for=\"fld_4421454_2\" class=\"control-label\">Problemas exclusivos para sexo Masculino <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1563715\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1563715\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1563715]\"\n                                value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                            >\n                    Dor durante rela\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1979733\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor durante ere\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1979733\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1979733]\"\n                                value=\"Dor durante ere\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor durante ere\u00e7\u00e3o\"\n                            >\n                    Dor durante ere\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1366036\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor durante ejacula\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1366036\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1366036]\"\n                                value=\"Dor durante ejacula\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor durante ejacula\u00e7\u00e3o\"\n                            >\n                    Dor durante ejacula\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1086262\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor durante mic\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1086262\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1086262]\"\n                                value=\"Dor durante mic\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor durante mic\u00e7\u00e3o\"\n                            >\n                    Dor durante mic\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1186040\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor na pr\u00f3stata\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1186040\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1186040]\"\n                                value=\"Dor na pr\u00f3stata\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor na pr\u00f3stata\"\n                            >\n                    Dor na pr\u00f3stata                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1741447\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1741447\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1741447]\"\n                                value=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dor ou incha\u00e7o nos test\u00edculos\"\n                            >\n                    Dor ou incha\u00e7o nos test\u00edculos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1436317\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Emiss\u00f5es noturnas\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1436317\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1436317]\"\n                                value=\"Emiss\u00f5es noturnas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Emiss\u00f5es noturnas\"\n                            >\n                    Emiss\u00f5es noturnas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1760455\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Ejacula\u00e7\u00e3o precoce\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1760455\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1760455]\"\n                                value=\"Ejacula\u00e7\u00e3o precoce\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Ejacula\u00e7\u00e3o precoce\"\n                            >\n                    Ejacula\u00e7\u00e3o precoce                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt2007966\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Dificuldade de ere\u00e7\u00e3o\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt2007966\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt2007966]\"\n                                value=\"Dificuldade de ere\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Dificuldade de ere\u00e7\u00e3o\"\n                            >\n                    Dificuldade de ere\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1646396\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Impot\u00eancia sexual\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1646396\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1646396]\"\n                                value=\"Impot\u00eancia sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Impot\u00eancia sexual\"\n                            >\n                    Impot\u00eancia sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt2070743\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Infertilidade\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt2070743\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt2070743]\"\n                                value=\"Infertilidade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Infertilidade\"\n                            >\n                    Infertilidade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt1276981\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00e3o possuo nenhum dos citados\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt1276981\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt1276981]\"\n                                value=\"N\u00e3o possuo nenhum dos citados\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"N\u00e3o possuo nenhum dos citados\"\n                            >\n                    N\u00e3o possuo nenhum dos citados                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4421454_2_opt2051047\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_4421454_2\" data-parsley-multiple=\"fld_4421454_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_4421454\"\n                                id=\"fld_4421454_2_opt2051047\"\n                                class=\"fld_4421454_2 option-required\"\n                                name=\"fld_4421454[opt2051047]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4421454_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7735289_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7735289\" class=\"form-group\" id=\"fld_7735289_2-wrap\">\r\n\t<label id=\"fld_7735289Label\" for=\"fld_7735289_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7735289\" class=\" form-control\" id=\"fld_7735289_2\" name=\"fld_7735289\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7735289Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1241280_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1241280\" class=\"form-group\" id=\"fld_1241280_2-wrap\">\r\n\t<label id=\"fld_1241280Label\" for=\"fld_1241280_2\" class=\"control-label\">Problemas exclusivos para sexo Feminino <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1200983\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1200983\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1200983]\"\n                                value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Dor durante rela\u00e7\u00e3o sexual\"\n                            >\n                    Dor durante rela\u00e7\u00e3o sexual                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1333721\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Problemas com orgasmo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1333721\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1333721]\"\n                                value=\"Problemas com orgasmo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Problemas com orgasmo\"\n                            >\n                    Problemas com orgasmo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1718785\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Secura vaginal\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1718785\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1718785]\"\n                                value=\"Secura vaginal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Secura vaginal\"\n                            >\n                    Secura vaginal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1057766\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Gravidez\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1057766\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1057766]\"\n                                value=\"Gravidez\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Gravidez\"\n                            >\n                    Gravidez                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1085322\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Aborto\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1085322\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1085322]\"\n                                value=\"Aborto\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Aborto\"\n                            >\n                    Aborto                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1641879\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Aborto espont\u00e2neo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1641879\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1641879]\"\n                                value=\"Aborto espont\u00e2neo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Aborto espont\u00e2neo\"\n                            >\n                    Aborto espont\u00e2neo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1094483\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Infertilidade\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1094483\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1094483]\"\n                                value=\"Infertilidade\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Infertilidade\"\n                            >\n                    Infertilidade                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1612625\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"N\u00f3dulos nas mamas\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1612625\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1612625]\"\n                                value=\"N\u00f3dulos nas mamas\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"N\u00f3dulos nas mamas\"\n                            >\n                    N\u00f3dulos nas mamas                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1319807\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menopausa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1319807\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1319807]\"\n                                value=\"Menopausa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menopausa\"\n                            >\n                    Menopausa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1081886\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Normal\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1081886\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1081886]\"\n                                value=\"Menstrua\u00e7\u00e3o - Normal\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Normal\"\n                            >\n                    Menstrua\u00e7\u00e3o - Normal                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1412242\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Cedo\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1412242\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1412242]\"\n                                value=\"Menstrua\u00e7\u00e3o - Cedo\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Cedo\"\n                            >\n                    Menstrua\u00e7\u00e3o - Cedo                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt2030432\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Tardia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt2030432\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt2030432]\"\n                                value=\"Menstrua\u00e7\u00e3o - Tardia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Tardia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Tardia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1077120\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Irregular\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1077120\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1077120]\"\n                                value=\"Menstrua\u00e7\u00e3o - Irregular\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Irregular\"\n                            >\n                    Menstrua\u00e7\u00e3o - Irregular                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1315473\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1315473\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1315473]\"\n                                value=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o\"\n                            >\n                    Menstrua\u00e7\u00e3o - Longa dura\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt2030002\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt2030002\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt2030002]\"\n                                value=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o\"\n                            >\n                    Menstrua\u00e7\u00e3o - Curta dura\u00e7\u00e3o                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1317140\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Pesada\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1317140\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1317140]\"\n                                value=\"Menstrua\u00e7\u00e3o - Pesada\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Pesada\"\n                            >\n                    Menstrua\u00e7\u00e3o - Pesada                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1618328\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Escassa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1618328\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1618328]\"\n                                value=\"Menstrua\u00e7\u00e3o - Escassa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Escassa\"\n                            >\n                    Menstrua\u00e7\u00e3o - Escassa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1326251\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1326251\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1326251]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dolorosa\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dolorosa                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1501510\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1501510\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1501510]\"\n                                value=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Metrorragia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Metrorragia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1784189\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1784189\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1784189]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dismenorreia\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dismenorreia                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt2095099\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt2095099\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt2095099]\"\n                                value=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos\"\n                            >\n                    Menstrua\u00e7\u00e3o - Co\u00e1gulos sangu\u00edneos                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1329220\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1329220\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1329220]\"\n                                value=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a\"\n                            >\n                    Menstrua\u00e7\u00e3o - Dores de cabe\u00e7a                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_1241280_2_opt1970402\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_1241280_2\" data-parsley-multiple=\"fld_1241280_2\"                                type=\"checkbox\"\n                                data-label=\"Outro\"\n                                data-field=\"fld_1241280\"\n                                id=\"fld_1241280_2_opt1970402\"\n                                class=\"fld_1241280_2 option-required\"\n                                name=\"fld_1241280[opt1970402]\"\n                                value=\"Outro\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_1241280_2\"\n                                                                data-calc-value=\"Outro\"\n                            >\n                    Outro                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_437986_2-tmpl\">\r\n<div data-field-wrapper=\"fld_437986\" class=\"form-group\" id=\"fld_437986_2-wrap\">\r\n\t<label id=\"fld_437986Label\" for=\"fld_437986_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_437986\" class=\" form-control\" id=\"fld_437986_2\" name=\"fld_437986\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_437986Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5184946_2-tmpl\">\r\n<div data-field-wrapper=\"fld_5184946\" class=\"form-group\" id=\"fld_5184946_2-wrap\">\r\n\t<label id=\"fld_5184946Label\" for=\"fld_5184946_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5184946\" class=\" form-control\" id=\"fld_5184946_2\" name=\"fld_5184946\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5184946Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_9781446_2-tmpl\">\r\n<div data-field-wrapper=\"fld_9781446\" class=\"form-group\" id=\"fld_9781446_2-wrap\">\r\n\t<label id=\"fld_9781446Label\" for=\"fld_9781446_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9781446\" class=\" form-control\" id=\"fld_9781446_2\" name=\"fld_9781446\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9781446Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_7632005_2-tmpl\">\r\n<div data-field-wrapper=\"fld_7632005\" class=\"form-group\" id=\"fld_7632005_2-wrap\">\r\n\t<label id=\"fld_7632005Label\" for=\"fld_7632005_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_7632005\" class=\" form-control\" id=\"fld_7632005_2\" name=\"fld_7632005\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_7632005Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_411163_2-tmpl\">\r\n<div data-field-wrapper=\"fld_411163\" class=\"form-group\" id=\"fld_411163_2-wrap\">\r\n\t<label id=\"fld_411163Label\" for=\"fld_411163_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_411163\" class=\" form-control\" id=\"fld_411163_2\" name=\"fld_411163\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_411163Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_846866_2-tmpl\">\r\n<div data-field-wrapper=\"fld_846866\" class=\"form-group\" id=\"fld_846866_2-wrap\">\r\n\t<label id=\"fld_846866Label\" for=\"fld_846866_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_846866\" class=\" form-control\" id=\"fld_846866_2\" name=\"fld_846866\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_846866Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_5703829_2-tmpl\">\r\n<div data-field-wrapper=\"fld_5703829\" class=\"form-group\" id=\"fld_5703829_2-wrap\">\r\n\t<label id=\"fld_5703829Label\" for=\"fld_5703829_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_5703829\" class=\" form-control\" id=\"fld_5703829_2\" name=\"fld_5703829\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_5703829Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1642058_2-tmpl\">\r\n<div data-field-wrapper=\"fld_1642058\" class=\"form-group\" id=\"fld_1642058_2-wrap\">\r\n\t<label id=\"fld_1642058Label\" for=\"fld_1642058_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_1642058\" class=\" form-control\" id=\"fld_1642058_2\" name=\"fld_1642058\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_1642058Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_2102016_2-tmpl\">\r\n<div data-field-wrapper=\"fld_2102016\" class=\"form-group\" id=\"fld_2102016_2-wrap\">\r\n\t<label id=\"fld_2102016Label\" for=\"fld_2102016_2\" class=\"control-label\">Qual? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_2102016\" class=\" form-control\" id=\"fld_2102016_2\" name=\"fld_2102016\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_2102016Label\" 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