{"id":580,"date":"2022-04-04T14:06:47","date_gmt":"2022-04-04T18:06:47","guid":{"rendered":"https:\/\/zenequilibre.com\/dev\/?page_id=580"},"modified":"2024-09-05T11:10:58","modified_gmt":"2024-09-05T15:10:58","slug":"formulaire-pre-rencontre","status":"publish","type":"page","link":"https:\/\/zenequilibre.com\/en\/formulaire-pre-rencontre\/","title":{"rendered":"Pre-meeting form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"580\" class=\"elementor elementor-580\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a22be1f elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"48809\" data-id=\"a22be1f\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8506e05\" data-eae-slider=\"82734\" data-id=\"8506e05\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f92782d elementor-widget elementor-widget-text-editor\" data-id=\"f92782d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Merci de remplir ce formulaire avant votre premi\u00e8re rencontre en t\u00e9l\u00e9consultation.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dc56241 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"dc56241\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Suivant&quot;,&quot;step_previous_label&quot;:&quot;Pr\\u00e9c\\u00e9dent&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Formulaire Pr\u00e9-Rencontre\" aria-label=\"Formulaire Pr\u00e9-Rencontre\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"580\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"dc56241\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Formulaire pr\u00e9-rencontre - Physio Kin Zen \u00c9quilibre\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"580\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_f20886f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Informations personnelles\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-prenom elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-prenom\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPr\u00e9nom\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[prenom]\" id=\"form-field-prenom\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Pr\u00e9nom\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-nom elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-nom\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNom\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[nom]\" id=\"form-field-nom\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nom\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-naissance elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-naissance\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate de naissance\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[naissance]\" id=\"form-field-naissance\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Date de naissance\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_099ff49 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_099ff49\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOccupation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_099ff49]\" id=\"form-field-field_099ff49\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Occupation\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_6f7bfa0 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6f7bfa0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAdresse\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_6f7bfa0]\" id=\"form-field-field_6f7bfa0\" rows=\"4\" placeholder=\"Adresse\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_31e8ad9 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_31e8ad9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tT\u00e9l\u00e9phone (Cellulaire)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_31e8ad9]\" id=\"form-field-field_31e8ad9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"T\u00e9l\u00e9phone (Cellulaire)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3a49533 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3a49533\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tT\u00e9l\u00e9phone (Maison)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3a49533]\" id=\"form-field-field_3a49533\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"T\u00e9l\u00e9phone (Maison)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_2209064 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2209064\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_2209064]\" id=\"form-field-field_2209064\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"E-mail\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_a53fbd6 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Ant\u00e9c\u00e9dents m\u00e9dicaux\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4d79ed3 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4d79ed3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVoyez-vous pr\u00e9sentement l'un des praticiens suivants :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"M\u00e9decin\" id=\"form-field-field_4d79ed3-0\" name=\"form_fields[field_4d79ed3][]\"> <label for=\"form-field-field_4d79ed3-0\">M\u00e9decin<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Chiropraticien\" id=\"form-field-field_4d79ed3-1\" name=\"form_fields[field_4d79ed3][]\"> <label for=\"form-field-field_4d79ed3-1\">Chiropraticien<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ost\u00e9opathe\" id=\"form-field-field_4d79ed3-2\" name=\"form_fields[field_4d79ed3][]\"> <label for=\"form-field-field_4d79ed3-2\">Ost\u00e9opathe<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aucune de ces r\u00e9ponses\" id=\"form-field-field_4d79ed3-3\" name=\"form_fields[field_4d79ed3][]\"> <label for=\"form-field-field_4d79ed3-3\">Aucune de ces r\u00e9ponses<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ffabd75 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ffabd75\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSouffrez-vous de l'une des maladies suivantes :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aucune maladie connue\" id=\"form-field-field_ffabd75-0\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-0\">Aucune maladie connue<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_ffabd75-1\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-1\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Haute tension art\u00e9rielle\" id=\"form-field-field_ffabd75-2\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-2\">Haute tension art\u00e9rielle<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diab\u00e8te\" id=\"form-field-field_ffabd75-3\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-3\">Diab\u00e8te<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"\u00c9pilepsie\" id=\"form-field-field_ffabd75-4\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-4\">\u00c9pilepsie<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Probl\u00e8me cardiaque\" id=\"form-field-field_ffabd75-5\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-5\">Probl\u00e8me cardiaque<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Probl\u00e8me d&#039;estomac\" id=\"form-field-field_ffabd75-6\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-6\">Probl\u00e8me d'estomac<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pr\u00e9sence de m\u00e9tal, Pacemaker\" id=\"form-field-field_ffabd75-7\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-7\">Pr\u00e9sence de m\u00e9tal, Pacemaker<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Probl\u00e8me circulatoire\" id=\"form-field-field_ffabd75-8\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-8\">Probl\u00e8me circulatoire<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"D\u00e9pendance chimique (drogue ou autres)\" id=\"form-field-field_ffabd75-9\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-9\">D\u00e9pendance chimique (drogue ou autres)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hypoglyc\u00e9,ie\" id=\"form-field-field_ffabd75-10\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-10\">Hypoglyc\u00e9,ie<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Probl\u00e8mes de glande thyro\u00efde\" id=\"form-field-field_ffabd75-11\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-11\">Probl\u00e8mes de glande thyro\u00efde<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Emphys\u00e8me\/Bronchite\" id=\"form-field-field_ffabd75-12\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-12\">Emphys\u00e8me\/Bronchite<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthme\" id=\"form-field-field_ffabd75-13\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-13\">Asthme<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Migraine\" id=\"form-field-field_ffabd75-14\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-14\">Migraine<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Arthrite rhumato\u00efde\" id=\"form-field-field_ffabd75-15\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-15\">Arthrite rhumato\u00efde<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Scl\u00e9rose en plaques\" id=\"form-field-field_ffabd75-16\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-16\">Scl\u00e9rose en plaques<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"D\u00e9pression\" id=\"form-field-field_ffabd75-17\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-17\">D\u00e9pression<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Autres conditions d&#039;arthrite\" id=\"form-field-field_ffabd75-18\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-18\">Autres conditions d'arthrite<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Accident c\u00e9r\u00e9bro-vasculaire\" id=\"form-field-field_ffabd75-19\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-19\">Accident c\u00e9r\u00e9bro-vasculaire<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"H\u00e9patite\" id=\"form-field-field_ffabd75-20\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-20\">H\u00e9patite<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"An\u00e9mie\" id=\"form-field-field_ffabd75-21\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-21\">An\u00e9mie<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Maladie r\u00e9nale\" id=\"form-field-field_ffabd75-22\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-22\">Maladie r\u00e9nale<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"VIH (Sida)\" id=\"form-field-field_ffabd75-23\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-23\">VIH (Sida)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ost\u00e9oporose\" id=\"form-field-field_ffabd75-24\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-24\">Ost\u00e9oporose<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Allergies\" id=\"form-field-field_ffabd75-25\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-25\">Allergies<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Autres\" id=\"form-field-field_ffabd75-26\" name=\"form_fields[field_ffabd75][]\"> <label for=\"form-field-field_ffabd75-26\">Autres<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a6644a7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6644a7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi OUI \u00e0 CANCER, lequel :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a6644a7]\" id=\"form-field-field_a6644a7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_be4286a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_be4286a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi OUI \u00e0 ALLERGIES, lesquelles :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_be4286a]\" id=\"form-field-field_be4286a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4ff6866 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ff6866\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi OUI \u00e0 AUTRE :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4ff6866]\" id=\"form-field-field_4ff6866\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d86f55b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d86f55b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEst-ce que votre poids est stable depuis les 6 derniers mois\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_d86f55b]\" id=\"form-field-field_d86f55b\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Oui\">Oui<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Non\">Non<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_5e91ae3 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e91ae3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIndiquez toute chirurgie ou autre condition pour laquelle vous avez \u00e9t\u00e9 hospitalis\u00e9, en mentionnant la DATE APPROXIMATIVE, ainsi que le motif chirurgical ou d'hospitalisation.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_5e91ae3]\" id=\"form-field-field_5e91ae3\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_7d15a9c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7d15a9c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIndiquez toute blessure pour laquelle vous avez \u00e9t\u00e9 trait\u00e9 (incluant fracture, entorse) en mentionnant la DATE APPROXIMATIVE\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_7d15a9c]\" id=\"form-field-field_7d15a9c\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_030c237 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_030c237\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tQuels m\u00e9dicaments SANS PRESCRIPTION prenez-vous ou avez-vous pris la semaine derni\u00e8re\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_030c237]\" id=\"form-field-field_030c237\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_23e740b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_23e740b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tQuels m\u00e9dicaments PRESCRITS prenez-vous ou avez-vous pris la semaine derni\u00e8re\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_23e740b]\" id=\"form-field-field_23e740b\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6beb47f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Consentement\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_6bd42f4 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_6bd42f4]\" id=\"form-field-field_6bd42f4\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_6bd42f4\">J'autorise ma physioth\u00e9rapeute \u00e0 effectuer les \u00e9valuations et suivis n\u00e9cessaires pour l'am\u00e9lioration de ma condition.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_ace946c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_ace946c]\" id=\"form-field-field_ace946c\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_ace946c\">J'autorise le partage d'informations entre les diff\u00e9rents intervenants concern\u00e9es par mon dossier (m\u00e9decin, physioth\u00e9rapeute, massoth\u00e9rapeute, ost\u00e9opathe, s'il y a lieu).<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_a74b9e8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_a74b9e8]\" id=\"form-field-field_a74b9e8\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_a74b9e8\">J'autorise ma physioth\u00e9rapeute \u00e0 consulter les rapports d'imagerie (IRM, radiographie, etc.), protocole post-op\u00e9ratoire ou autres afin de pouvoir adapter mes traitements.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_066397d elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_066397d]\" id=\"form-field-field_066397d\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_066397d\">J'autorise ma physioth\u00e9rapeute \u00e0 envoyer les rapports aux personnes impliqu\u00e9es dans mon dossier (m\u00e9decins, sp\u00e9cialistes, autres th\u00e9rapeutes).<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_70096aa elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_70096aa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAcceptation de la transmission de la fiche m\u00e9dicale\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_70096aa]\" id=\"form-field-field_70096aa\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_70096aa\">J'accepte la transmision des informations personnelles ci-dessus. Si je d\u00e9sire annuler mon rendez-vous, je le ferai au moins 24 heures \u00e0 l'avance.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_169a620 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_169a620\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LdqWjAqAAAAALXTQU8RPPCRiUMGSElyAGrTxh1b\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Envoyer<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please fill out this form before your first teleconsultation meeting.<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-580","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Formulaire pr\u00e9-rencontre - Physio Kin Zen \u00c9quilibre<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/zenequilibre.com\/en\/formulaire-pre-rencontre\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulaire pr\u00e9-rencontre - Physio Kin Zen \u00c9quilibre\" \/>\n<meta property=\"og:description\" content=\"Merci de remplir ce formulaire avant votre premi\u00e8re rencontre en t\u00e9l\u00e9consultation.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/zenequilibre.com\/en\/formulaire-pre-rencontre\/\" \/>\n<meta property=\"og:site_name\" content=\"Physio Kin Zen \u00c9quilibre\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/PhysioKinZenEquilibre\" \/>\n<meta property=\"article:modified_time\" content=\"2024-09-05T15:10:58+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/zenequilibre.com\/wp-content\/uploads\/2022\/05\/ZenEquilibre_ImageDePartage.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"1920\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/zenequilibre.com\\\/formulaire-pre-rencontre\\\/\",\"url\":\"https:\\\/\\\/zenequilibre.com\\\/formulaire-pre-rencontre\\\/\",\"name\":\"Formulaire pr\u00e9-rencontre - Physio Kin Zen \u00c9quilibre\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/zenequilibre.com\\\/#website\"},\"datePublished\":\"2022-04-04T18:06:47+00:00\",\"dateModified\":\"2024-09-05T15:10:58+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/zenequilibre.com\\\/formulaire-pre-rencontre\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/zenequilibre.com\\\/formulaire-pre-rencontre\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/zenequilibre.com\\\/formulaire-pre-rencontre\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Accueil\",\"item\":\"https:\\\/\\\/zenequilibre.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Formulaire pr\u00e9-rencontre\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/zenequilibre.com\\\/#website\",\"url\":\"https:\\\/\\\/zenequilibre.com\\\/\",\"name\":\"Physio Kin Zen \u00c9quilibre\",\"description\":\"Services de physioth\u00e9rapie\\\/kin\u00e9siologie en clinique et \u00e0 domicile. 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