{"id":70801,"date":"2022-05-23T15:13:30","date_gmt":"2022-05-23T19:13:30","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=70801"},"modified":"2026-03-06T14:44:31","modified_gmt":"2026-03-06T19:44:31","slug":"adhd","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/adhd\/","title":{"rendered":"Prueba de TDAH"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_27' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_27'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/70801' data-formid='27' novalidate><ol class=\"screen-progress-bar clearfix step-1-of-3\">\n\t\t\t\t\t<li class=\"step-1\"><span>Test<br \/>Questions<\/span><\/li>\n\t\t\t\t\t<li class=\"step-2\"><span>Optional<br \/>Questions<\/span><\/li>\n\t\t\t\t\t<li class=\"step-3\"><span>Your<br \/>Results<\/span><\/li>\n\t\t\t\t<\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_27_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_27' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_27_139\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_139'>URL<\/label><div class='gfield_description' id='gfield_description_27_139'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_139' id='input_27_139' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_27_38\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_38' id='input_27_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_39\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_39\" id=\"input_27_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"70801\"><\/div><div id=\"field_27_40\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_40\" id=\"input_27_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"1065b15f1fb646497a4b06db21f9fba2\"><\/div><div id=\"field_27_41\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_41' id='input_27_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_53\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_53' id='input_27_53' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_27_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_84\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_84' id='input_27_84' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_85\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_85' id='input_27_85' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_111\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_111' id='input_27_111' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_27_114\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_114' id='input_27_114' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen\/70801' \/><\/div><\/div><div id=\"field_27_138\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_138' id='input_27_138' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_27_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Everyone has times when they have trouble concentrating or keeping their mind on what they are doing. What we want to know is whether you have had difficulty concentrating or keeping your  mind on what you are doing most of the time.<\/div><fieldset id=\"field_27_118\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often had trouble  keeping your mind on what you were doing most  of the time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_118'>\n\t\t\t<div class='gchoice gchoice_27_118_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Yes'  id='choice_27_118_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_118_0' id='label_27_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_118_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='No'  id='choice_27_118_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_118_1' id='label_27_118_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often forgotten what you are supposed to be doing or what you had planned to do?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_120'>\n\t\t\t<div class='gchoice gchoice_27_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='Yes'  id='choice_27_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_120_0' id='label_27_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='No'  id='choice_27_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_120_1' id='label_27_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often found it hard to keep your mind on what you are doing when other things are going on?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_121'>\n\t\t\t<div class='gchoice gchoice_27_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Yes'  id='choice_27_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_121_0' id='label_27_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='No'  id='choice_27_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_121_1' id='label_27_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often tried not to do things where you would need to pay attention for a long time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_122'>\n\t\t\t<div class='gchoice gchoice_27_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Yes'  id='choice_27_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_122_0' id='label_27_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='No'  id='choice_27_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_122_1' id='label_27_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often made a lot of mistakes because it's hard for you to do things carefully?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_123'>\n\t\t\t<div class='gchoice gchoice_27_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Yes'  id='choice_27_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_123_0' id='label_27_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='No'  id='choice_27_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_123_1' id='label_27_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often felt fidgety, physically restless, or felt like you always had to be moving or doing something? Has it been difficult to stay still for any length of time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_124'>\n\t\t\t<div class='gchoice gchoice_27_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Yes'  id='choice_27_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_124_0' id='label_27_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='No'  id='choice_27_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_124_1' id='label_27_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >In the last <strong>year<\/strong>, have you taken medication for being overactive, being hyperactive, or having trouble paying attention?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_125'>\n\t\t\t<div class='gchoice gchoice_27_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Yes'  id='choice_27_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_125_0' id='label_27_125_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='No'  id='choice_27_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_125_1' id='label_27_125_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_119\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_27_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Please answer the questions below, rating yourself on each of the criteria shown. As you answer each question, select the button that best describes how you have felt and conducted yourself <strong>over the past 6 months<\/strong>.<\/div><fieldset id=\"field_27_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_5'>\n\t\t\t<div class='gchoice gchoice_27_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0.0001'  id='choice_27_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_5_0' id='label_27_5_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0'  id='choice_27_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_5_1' id='label_27_5_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1.0001'  id='choice_27_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_5_2' id='label_27_5_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1.00001'  id='choice_27_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_5_3' id='label_27_5_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_5_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1'  id='choice_27_5_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_5_4' id='label_27_5_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. How often do you have difficulty getting things in order when you have to do a task that requires organization?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_47'>\n\t\t\t<div class='gchoice gchoice_27_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_27_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_47_0' id='label_27_47_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0.0001'  id='choice_27_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_47_1' id='label_27_47_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_27_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_47_2' id='label_27_47_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1.0001'  id='choice_27_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_47_3' id='label_27_47_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_47_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1.00001'  id='choice_27_47_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_47_4' id='label_27_47_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. How often do you have problems remembering appointments or obligations?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_48'>\n\t\t\t<div class='gchoice gchoice_27_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0'  id='choice_27_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_48_0' id='label_27_48_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0.0001'  id='choice_27_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_48_1' id='label_27_48_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_27_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_48_2' id='label_27_48_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1.0001'  id='choice_27_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_48_3' id='label_27_48_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_48_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1.00001'  id='choice_27_48_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_48_4' id='label_27_48_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_49'>\n\t\t\t<div class='gchoice gchoice_27_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0'  id='choice_27_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_49_0' id='label_27_49_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0.00001'  id='choice_27_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_49_1' id='label_27_49_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0.0001'  id='choice_27_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_49_2' id='label_27_49_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1'  id='choice_27_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_49_3' id='label_27_49_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_49_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1.0001'  id='choice_27_49_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_49_4' id='label_27_49_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_96'>\n\t\t\t<div class='gchoice gchoice_27_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='0'  id='choice_27_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_96_0' id='label_27_96_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='0.0001'  id='choice_27_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_96_1' id='label_27_96_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_96_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='0.00001'  id='choice_27_96_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_96_2' id='label_27_96_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_96_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='1.00001'  id='choice_27_96_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_96_3' id='label_27_96_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_96_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='1'  id='choice_27_96_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_96_4' id='label_27_96_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. How often do you feel overly active and compelled to do things, like you were driven by a motor?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_105'>\n\t\t\t<div class='gchoice gchoice_27_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='0'  id='choice_27_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_105_0' id='label_27_105_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='0.0001'  id='choice_27_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_105_1' id='label_27_105_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_105_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='0.00001'  id='choice_27_105_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_105_2' id='label_27_105_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_105_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='1'  id='choice_27_105_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_105_3' id='label_27_105_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_105_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='1.00001'  id='choice_27_105_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_105_4' id='label_27_105_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. How often do you make careless mistakes when you have to work on a boring or difficult project?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_104'>\n\t\t\t<div class='gchoice gchoice_27_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='0'  id='choice_27_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_104_0' id='label_27_104_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='0.0001'  id='choice_27_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_104_1' id='label_27_104_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_104_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='0.00001'  id='choice_27_104_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_104_2' id='label_27_104_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_104_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='1'  id='choice_27_104_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_104_3' id='label_27_104_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_104_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='1.00001'  id='choice_27_104_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_104_4' id='label_27_104_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_103'>\n\t\t\t<div class='gchoice gchoice_27_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='0'  id='choice_27_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_103_0' id='label_27_103_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='0.00001'  id='choice_27_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_103_1' id='label_27_103_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_103_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='0.0001'  id='choice_27_103_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_103_2' id='label_27_103_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_103_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='1'  id='choice_27_103_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_103_3' id='label_27_103_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_103_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='1.00001'  id='choice_27_103_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_103_4' id='label_27_103_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_102\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_102'>\n\t\t\t<div class='gchoice gchoice_27_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='0'  id='choice_27_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_102_0' id='label_27_102_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='0.00001'  id='choice_27_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_102_1' id='label_27_102_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_102_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='1'  id='choice_27_102_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_102_2' id='label_27_102_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_102_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='1.00001'  id='choice_27_102_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_102_3' id='label_27_102_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_102_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='1.0001'  id='choice_27_102_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_102_4' id='label_27_102_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >10. How often do you misplace or have difficulty finding things at home or at work?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_101'>\n\t\t\t<div class='gchoice gchoice_27_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='0'  id='choice_27_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_101_0' id='label_27_101_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='0.0001'  id='choice_27_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_101_1' id='label_27_101_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_101_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='0.00001'  id='choice_27_101_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_101_2' id='label_27_101_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_101_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='1'  id='choice_27_101_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_101_3' id='label_27_101_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_101_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='1.0001'  id='choice_27_101_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_101_4' id='label_27_101_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_106\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >11. How often are you distracted by activity or noise around you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_106'>\n\t\t\t<div class='gchoice gchoice_27_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='0'  id='choice_27_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_106_0' id='label_27_106_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='0.0001'  id='choice_27_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_106_1' id='label_27_106_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_106_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='0.00001'  id='choice_27_106_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_106_2' id='label_27_106_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_106_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='1.0001'  id='choice_27_106_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_106_3' id='label_27_106_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_106_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='1'  id='choice_27_106_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_106_4' id='label_27_106_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_100\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_100'>\n\t\t\t<div class='gchoice gchoice_27_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='0'  id='choice_27_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_100_0' id='label_27_100_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='0.0001'  id='choice_27_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_100_1' id='label_27_100_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_100_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='1.0001'  id='choice_27_100_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_100_2' id='label_27_100_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_100_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='1.00001'  id='choice_27_100_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_100_3' id='label_27_100_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_100_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='1'  id='choice_27_100_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_100_4' id='label_27_100_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >13. How often do you feel restless or fidgety?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_99'>\n\t\t\t<div class='gchoice gchoice_27_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='0'  id='choice_27_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_99_0' id='label_27_99_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='0.0001'  id='choice_27_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_99_1' id='label_27_99_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_99_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='0.00001'  id='choice_27_99_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_99_2' id='label_27_99_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_99_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='1'  id='choice_27_99_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_99_3' id='label_27_99_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_99_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='1.0001'  id='choice_27_99_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_99_4' id='label_27_99_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >14. How often do you have difficulty unwinding and relaxing when you have time to yourself?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_98'>\n\t\t\t<div class='gchoice gchoice_27_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='0'  id='choice_27_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_98_0' id='label_27_98_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='0.0001'  id='choice_27_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_98_1' id='label_27_98_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_98_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='0.00001'  id='choice_27_98_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_98_2' id='label_27_98_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_98_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='1.0001'  id='choice_27_98_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_98_3' id='label_27_98_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_98_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='1'  id='choice_27_98_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_98_4' id='label_27_98_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >15. How often do you find yourself talking too much when you are in social situations?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_97'>\n\t\t\t<div class='gchoice gchoice_27_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='0'  id='choice_27_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_97_0' id='label_27_97_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='0.0001'  id='choice_27_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_97_1' id='label_27_97_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_97_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='0.00001'  id='choice_27_97_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_97_2' id='label_27_97_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_97_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='1.0001'  id='choice_27_97_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_97_3' id='label_27_97_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_97_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='1'  id='choice_27_97_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_97_4' id='label_27_97_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >16. When you\u2019re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_109'>\n\t\t\t<div class='gchoice gchoice_27_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='0'  id='choice_27_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_109_0' id='label_27_109_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='0.0001'  id='choice_27_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_109_1' id='label_27_109_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_109_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='1.0001'  id='choice_27_109_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_109_2' id='label_27_109_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_109_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='1.00001'  id='choice_27_109_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_109_3' id='label_27_109_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_109_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='1'  id='choice_27_109_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_109_4' id='label_27_109_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >17. How often do you have difficulty waiting your turn in situations when turn taking is required?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_108'>\n\t\t\t<div class='gchoice gchoice_27_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='0'  id='choice_27_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_108_0' id='label_27_108_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='0.0001'  id='choice_27_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_108_1' id='label_27_108_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_108_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='0.00001'  id='choice_27_108_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_108_2' id='label_27_108_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_108_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='1.0001'  id='choice_27_108_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_108_3' id='label_27_108_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_108_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='1'  id='choice_27_108_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_108_4' id='label_27_108_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question exclude gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >18. How often do you interrupt others when they are busy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_107'>\n\t\t\t<div class='gchoice gchoice_27_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='0'  id='choice_27_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_107_0' id='label_27_107_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='0.0001'  id='choice_27_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_107_1' id='label_27_107_1' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_107_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='1.0001'  id='choice_27_107_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_107_2' id='label_27_107_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_107_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='1.00001'  id='choice_27_107_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_107_3' id='label_27_107_3' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_107_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='1'  id='choice_27_107_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_107_4' id='label_27_107_4' class='gform-field-label gform-field-label--type-inline'>Very Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_127\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/>\n\nEveryone has times when they have trouble concentrating or keeping their mind on what they are doing. What we want to know is whether you have had difficulty concentrating or keeping your  mind on what you are doing most of the time.<\/div><fieldset id=\"field_27_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often had trouble  keeping your mind on what you were doing most  of the time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_128'>\n\t\t\t<div class='gchoice gchoice_27_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Yes'  id='choice_27_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_128_0' id='label_27_128_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='No'  id='choice_27_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_128_1' id='label_27_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often forgotten what you are supposed to be doing or what you had planned to do?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_129'>\n\t\t\t<div class='gchoice gchoice_27_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Yes'  id='choice_27_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_129_0' id='label_27_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No'  id='choice_27_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_129_1' id='label_27_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often found it hard to keep your mind on what you are doing when other things are going on?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_130'>\n\t\t\t<div class='gchoice gchoice_27_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Yes'  id='choice_27_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_130_0' id='label_27_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_27_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_130_1' id='label_27_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often tried not to do things where you would need to pay attention for a long time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_131'>\n\t\t\t<div class='gchoice gchoice_27_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Yes'  id='choice_27_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_131_0' id='label_27_131_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='No'  id='choice_27_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_131_1' id='label_27_131_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often made a lot of mistakes because it's hard for you to do things carefully?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_132'>\n\t\t\t<div class='gchoice gchoice_27_132_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='Yes'  id='choice_27_132_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_132_0' id='label_27_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_132_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='No'  id='choice_27_132_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_132_1' id='label_27_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months,<\/strong> have you often felt fidgety, physically restless, or felt like you always had to be moving or doing something? Has it been difficult to stay still for any length of time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_133'>\n\t\t\t<div class='gchoice gchoice_27_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Yes'  id='choice_27_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_133_0' id='label_27_133_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='No'  id='choice_27_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_133_1' id='label_27_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >In the last <strong>year<\/strong>, have you taken medication for being overactive, being hyperactive, or having trouble paying attention?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_134'>\n\t\t\t<div class='gchoice gchoice_27_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Yes'  id='choice_27_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_134_0' id='label_27_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_27_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_134_1' id='label_27_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_27_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_27_2' class='gform_page demographics' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_27_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_27_54\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please take a moment to answer the following <strong>optional<\/strong> questions. Your answers are totally anonymous\u2014we won't be able to identify you based on this information. Your answers help us provide better information and support for people like you.<\/p>\n\n<p>You can answer as many or as few questions as you would like. When you are done, scroll to the bottom of the survey and click \"submit\" to receive your screening results.<\/p><\/div><div id=\"field_27_90\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><fieldset id=\"field_27_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you taking this test for yourself or for someone else?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_87'>\n\t\t\t<div class='gchoice gchoice_27_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For myself'  id='choice_27_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_87_0' id='label_27_87_0' class='gform-field-label gform-field-label--type-inline'>For myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For someone else'  id='choice_27_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_87_1' id='label_27_87_1' class='gform-field-label gform-field-label--type-inline'>For someone else<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_88\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >If you are taking this test for someone else, <strong>please use that person's information<\/strong> for the questions below, or leave them blank if you don't know the answer. Remember, <em>these questions are optional<\/em>.<\/div><div id=\"field_27_55\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About You<\/h2><\/div><div id=\"field_27_56\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_56'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_27_56' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><\/select><\/div><\/div><fieldset id=\"field_27_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_57'>\n\t\t\t<div class='gchoice gchoice_27_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Female'  id='choice_27_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_57_0' id='label_27_57_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Male'  id='choice_27_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_57_1' id='label_27_57_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non-Binary'  id='choice_27_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_57_2' id='label_27_57_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you identify as transgender?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_135'>\n\t\t\t<div class='gchoice gchoice_27_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Yes'  id='choice_27_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_135_0' id='label_27_135_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='No'  id='choice_27_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_135_1' id='label_27_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_58\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_58'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_27_58' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_27_60\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_60'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_27_60' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian or Alaska Native' >American Indian or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American (non-Hispanic)' >Black or African American (non-Hispanic)<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White (non-Hispanic)' >White (non-Hispanic)<\/option><option value='More than one of the above' >More than one of the above<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_27_61\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_61'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_27_61' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than $20,000' >Less than $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_27_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_91'>\n\t\t\t<div class='gchoice gchoice_27_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='I live in the United States'  id='choice_27_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_91_0' id='label_27_91_0' class='gform-field-label gform-field-label--type-inline'>I live in the United States<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='I live in another country'  id='choice_27_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_91_1' id='label_27_91_1' class='gform-field-label gform-field-label--type-inline'>I live in another country<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_80'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_27_80' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='I live in a U.S. Territory' >I live in a U.S. Territory<\/option><\/select><\/div><\/div><div id=\"field_27_82\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_82'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_82' id='input_27_82' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><div id=\"field_27_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_81'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_27_81' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_27_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following populations describes you?<\/legend><div class='gfield_description' id='gfield_description_27_62'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_27_62'><div class='gchoice gchoice_27_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_27_62_1'   aria-describedby=\"gfield_description_27_62\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_1' id='label_27_62_1' class='gform-field-label gform-field-label--type-inline'>Veteran or active-duty military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_27_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_2' id='label_27_62_2' class='gform-field-label gform-field-label--type-inline'>Caregiver of someone living with emotional or physical illness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='LGBTQ+'  id='choice_27_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_3' id='label_27_62_3' class='gform-field-label gform-field-label--type-inline'>LGBTQ+<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.4' type='checkbox'  value='Student'  id='choice_27_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_4' id='label_27_62_4' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.5' type='checkbox'  value='Trauma survivor'  id='choice_27_62_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_5' id='label_27_62_5' class='gform-field-label gform-field-label--type-inline'>Trauma survivor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.6' type='checkbox'  value='New or expecting parent'  id='choice_27_62_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_6' id='label_27_62_6' class='gform-field-label gform-field-label--type-inline'>New or expecting parent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_62_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.7' type='checkbox'  value='Healthcare worker'  id='choice_27_62_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_62_7' id='label_27_62_7' class='gform-field-label gform-field-label--type-inline'>Healthcare worker<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_92\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you caring for someone with a mental or physical health condition?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_92'>\n\t\t\t<div class='gchoice gchoice_27_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Mental health condition'  id='choice_27_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_92_0' id='label_27_92_0' class='gform-field-label gform-field-label--type-inline'>Mental health condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Physical health condition'  id='choice_27_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_92_1' id='label_27_92_1' class='gform-field-label gform-field-label--type-inline'>Physical health condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_92_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Both mental and physical health conditions'  id='choice_27_92_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_92_2' id='label_27_92_2' class='gform-field-label gform-field-label--type-inline'>Both mental and physical health conditions<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_93\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_93'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_27_93' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Lesbian or Gay' >Lesbian or Gay<\/option><option value='Bisexual' >Bisexual<\/option><option value='Queer' >Queer<\/option><option value='Pansexual' >Pansexual<\/option><option value='Asexual' >Asexual<\/option><option value='Straight' >Straight<\/option><option value='Other...' >Other...<\/option><\/select><\/div><\/div><div id=\"field_27_68\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_68'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_27_68' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_27_94\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following describe your experience of trauma?<\/legend><div class='gfield_description' id='gfield_description_27_94'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_27_94'><div class='gchoice gchoice_27_94_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.1' type='checkbox'  value='Child abuse\/violence'  id='choice_27_94_1'   aria-describedby=\"gfield_description_27_94\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_1' id='label_27_94_1' class='gform-field-label gform-field-label--type-inline'>Child abuse\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.2' type='checkbox'  value='Intimate partner violence'  id='choice_27_94_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_2' id='label_27_94_2' class='gform-field-label gform-field-label--type-inline'>Intimate partner violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_27_94_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_3' id='label_27_94_3' class='gform-field-label gform-field-label--type-inline'>Sexual assault\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_27_94_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_4' id='label_27_94_4' class='gform-field-label gform-field-label--type-inline'>Serious illness\/injury\/assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_27_94_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_5' id='label_27_94_5' class='gform-field-label gform-field-label--type-inline'>Family conflict (identity acceptance\/separation\/divorce)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_27_94_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_6' id='label_27_94_6' class='gform-field-label gform-field-label--type-inline'>Traumatic event (natural disaster, accident, witnessing violence, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.7' type='checkbox'  value='Death of a loved one'  id='choice_27_94_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_7' id='label_27_94_7' class='gform-field-label gform-field-label--type-inline'>Death of a loved one<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_94_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_27_94_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_94_8' id='label_27_94_8' class='gform-field-label gform-field-label--type-inline'>Other and\/or tell us more about your trauma<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_95\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_95'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_27_95' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_27_69\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About Your Mental Health<\/h2><\/div><fieldset id=\"field_27_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received treatment\/support for a mental health problem?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_71'>\n\t\t\t<div class='gchoice gchoice_27_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_27_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_71_0' id='label_27_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_27_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_71_1' id='label_27_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you receiving treatment\/support now?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_72'>\n\t\t\t<div class='gchoice gchoice_27_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_27_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_72_0' id='label_27_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_27_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_72_1' id='label_27_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_136\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What has prevented you from seeking treatment in the past?<\/legend><div class='gfield_description' id='gfield_description_27_136'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_27_136'><div class='gchoice gchoice_27_136_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_27_136_1'   aria-describedby=\"gfield_description_27_136\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_1' id='label_27_136_1' class='gform-field-label gform-field-label--type-inline'>I wanted to handle my mental health on my own<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_27_136_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_2' id='label_27_136_2' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t know how or where to start<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.3' type='checkbox'  value='I thought it would cost too much'  id='choice_27_136_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_3' id='label_27_136_3' class='gform-field-label gform-field-label--type-inline'>I thought it would cost too much<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_27_136_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_4' id='label_27_136_4' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t have time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_27_136_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_5' id='label_27_136_5' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t think it would help me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_27_136_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_6' id='label_27_136_6' class='gform-field-label gform-field-label--type-inline'>I didn't feel ready to start treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_27_136_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_7' id='label_27_136_7' class='gform-field-label gform-field-label--type-inline'>I was worried about what people would think or say if I got treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_27_136_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_8' id='label_27_136_8' class='gform-field-label gform-field-label--type-inline'>I was afraid of being forced into a hospital or forced to take medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_27_136_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_9' id='label_27_136_9' class='gform-field-label gform-field-label--type-inline'>I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_27_136_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_11' id='label_27_136_11' class='gform-field-label gform-field-label--type-inline'>My parent(s) or guardian wouldn't let me, or I didn't want to ask<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_136_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.12' type='checkbox'  value='Other...'  id='choice_27_136_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_136_12' id='label_27_136_12' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_137'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_27_137' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_27_73\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Think about your mental health test. What are the main things contributing to your mental health problems right now?<\/legend><div class='gfield_description' id='gfield_description_27_73'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_27_73'><div class='gchoice gchoice_27_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Abuse or violence'  id='choice_27_73_1'   aria-describedby=\"gfield_description_27_73\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_1' id='label_27_73_1' class='gform-field-label gform-field-label--type-inline'>Abuse or violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_27_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_2' id='label_27_73_2' class='gform-field-label gform-field-label--type-inline'>Relationship problems (friends, family, or significant other)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.3' type='checkbox'  value='Body image'  id='choice_27_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_3' id='label_27_73_3' class='gform-field-label gform-field-label--type-inline'>Body image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_27_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_4' id='label_27_73_4' class='gform-field-label gform-field-label--type-inline'>Low self-esteem or self-image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.5' type='checkbox'  value='School or work problems'  id='choice_27_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_5' id='label_27_73_5' class='gform-field-label gform-field-label--type-inline'>School or work problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.6' type='checkbox'  value='Financial problems'  id='choice_27_73_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_6' id='label_27_73_6' class='gform-field-label gform-field-label--type-inline'>Financial problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.7' type='checkbox'  value='Loneliness or isolation'  id='choice_27_73_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_7' id='label_27_73_7' class='gform-field-label gform-field-label--type-inline'>Loneliness or isolation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_27_73_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_8' id='label_27_73_8' class='gform-field-label gform-field-label--type-inline'>Grief or loss of someone or something<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_27_73_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_9' id='label_27_73_9' class='gform-field-label gform-field-label--type-inline'>Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_27_73_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_11' id='label_27_73_11' class='gform-field-label gform-field-label--type-inline'>State of the world (war, climate, politics, immigration)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_27_73_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_12' id='label_27_73_12' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know (something just feels wrong)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_73_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.13' type='checkbox'  value='Other...'  id='choice_27_73_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_73_13' id='label_27_73_13' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_27_74\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_74'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_27_74' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_27_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_110'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_27_110' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_27_75\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About Your Health<\/h2><\/div><fieldset id=\"field_27_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you currently have health insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_27_76'>\n\t\t\t<div class='gchoice gchoice_27_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_27_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_76_0' id='label_27_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_27_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_76_1' id='label_27_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_27_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='I don&#039;t know'  id='choice_27_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_27_76_2' id='label_27_76_2' class='gform-field-label gform-field-label--type-inline'>I don't know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_27_77\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any of the following physical health conditions?<\/legend><div class='gfield_description' id='gfield_description_27_77'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_27_77'><div class='gchoice gchoice_27_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Heart disease'  id='choice_27_77_1'   aria-describedby=\"gfield_description_27_77\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_27_77_1' id='label_27_77_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_27_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_77_2' id='label_27_77_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Diabetes'  id='choice_27_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_77_3' id='label_27_77_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_27_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='Cancer'  id='choice_27_77_4'   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(2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. <em>Psychological medicine, 35<\/em>(2), 245\u2013256. <a href=\"https:\/\/doi.org\/10.1017\/s0033291704002892\">https:\/\/doi.org\/10.1017\/s0033291704002892<\/a><\/p>\n<p>The ASRS v1.1 has been validated for adults as well as adolescents ages 13 and up. For more information, <a href=\"https:\/\/screening.mhanational.org\/about-our-screening-tools\/\">click here<\/a>.<\/p>\n<p><a href=\"https:\/\/screening.mhanational.org\/about-our-mental-health-tests\/\" target=\"_blank\" rel=\"noopener\">For more information about our screening tools, please click here.<\/a><\/p>\n<p><em><strong>Please note:<\/strong> Online screening tools are not diagnostic instruments. You are encouraged to share your results with a physician or healthcare provider. Mental Health America Inc., sponsors, partners, and advertisers disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, of the use and application of these screens.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para personas de todas las edades que tienen problemas para concentrarse, recordar cosas, completar tareas y\/o permanecer quietas.<\/p>","protected":false},"template":"","tags":[],"age_group":[],"condition":[82],"class_list":["post-70801","screen","type-screen","status-publish","hentry","condition-adhd"],"acf":[],"yoast_head":"<title>ADHD Test &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"Trouble focusing at school or at work? 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