{"id":2392,"date":"2021-06-01T12:13:59","date_gmt":"2021-06-01T12:13:59","guid":{"rendered":"https:\/\/teamimpaact.com.au\/?page_id=2392"},"modified":"2022-06-14T11:00:04","modified_gmt":"2022-06-14T11:00:04","slug":"readiness-for-change","status":"publish","type":"page","link":"https:\/\/teamimpaact.com.au\/readiness-for-change\/","title":{"rendered":"Readiness For Change"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.26.3&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;3.26.3&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.26.3&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_code module_class=&#8221;waiver-form newform-holder&#8221; _builder_version=&#8221;4.5.6&#8243; global_colors_info=&#8221;{}&#8221;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\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_11' ><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div>\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' target='gform_ajax_frame_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/2392#gf_11' data-formid='11' >\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' >\n                                    <div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_11_1\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_1\"><h2>Readiness for Change<\/h2>\n<p><\/p><\/div><fieldset id=\"field_11_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_2\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_11_2'>\n                            \n                            <span id='input_11_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_11_2_3' value='' tabindex='50'  aria-required='true'     \/>\n                                                    <label for='input_11_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_11_2_6' value='' tabindex='52'  aria-required='true'     \/>\n                                                    <label for='input_11_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_11_3\"  class=\"gfield gfield--type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_3\"><label class='gfield_label gform-field-label' for='input_11_3' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_11_3' type='text' value='' class='large' tabindex='54'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_4\"  class=\"gfield gfield--type-phone gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_4\"><label class='gfield_label gform-field-label' for='input_11_4' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_11_4' type='text' value='' class='large' tabindex='55'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_5\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_5\"><legend class='gfield_label gform-field-label'  >Do you look in the mirror and feel Frustrated, upset, or humiliated because of how your body looks?<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_11_5'>\n\t\t\t<div class='gchoice gchoice_11_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes (+3)'  id='choice_11_5_0' onchange='gformToggleRadioOther( this )'  tabindex='56'  \/>\n\t\t\t\t\t<label for='choice_11_5_0' id='label_11_5_0' class='gform-field-label gform-field-label--type-inline'>Yes (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='I&#039;m not sure (0)'  id='choice_11_5_1' onchange='gformToggleRadioOther( this )'  tabindex='57'  \/>\n\t\t\t\t\t<label for='choice_11_5_1' id='label_11_5_1' class='gform-field-label gform-field-label--type-inline'>I'm not sure (0)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No (-3)'  id='choice_11_5_2' onchange='gformToggleRadioOther( this )'  tabindex='58'  \/>\n\t\t\t\t\t<label for='choice_11_5_2' id='label_11_5_2' class='gform-field-label gform-field-label--type-inline'>No (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_6\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_6\"><legend class='gfield_label gform-field-label'  >When you feel run down and tired, what do you think is the source of these feelings?<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_11_6'>\n\t\t\t<div class='gchoice gchoice_11_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Getting older (-1)'  id='choice_11_6_0' onchange='gformToggleRadioOther( this )'  tabindex='59'  \/>\n\t\t\t\t\t<label for='choice_11_6_0' id='label_11_6_0' class='gform-field-label gform-field-label--type-inline'>Getting older (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='My lifestyle choices (+3)'  id='choice_11_6_1' onchange='gformToggleRadioOther( this )'  tabindex='60'  \/>\n\t\t\t\t\t<label for='choice_11_6_1' id='label_11_6_1' class='gform-field-label gform-field-label--type-inline'>My lifestyle choices (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Something else altogether (-3)'  id='choice_11_6_2' onchange='gformToggleRadioOther( this )'  tabindex='61'  \/>\n\t\t\t\t\t<label for='choice_11_6_2' id='label_11_6_2' class='gform-field-label gform-field-label--type-inline'>Something else altogether (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_7\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_7\"><legend class='gfield_label gform-field-label'  >Are you taking any medications for heart disease, high blood pressure, or type Il diabetes that you didn&#039;t have to take when you were younger?<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_11_7'>\n\t\t\t<div class='gchoice gchoice_11_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes, I&#039;m on two or more of these medications (+3)'  id='choice_11_7_0' onchange='gformToggleRadioOther( this )'  tabindex='62'  \/>\n\t\t\t\t\t<label for='choice_11_7_0' id='label_11_7_0' class='gform-field-label gform-field-label--type-inline'>Yes, I'm on two or more of these medications (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes, I&#039;m on only one of these medications (+1)'  id='choice_11_7_1' onchange='gformToggleRadioOther( this )'  tabindex='63'  \/>\n\t\t\t\t\t<label for='choice_11_7_1' id='label_11_7_1' class='gform-field-label gform-field-label--type-inline'>Yes, I'm on only one of these medications (+1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No, I&#039;m not on any of these medications (-3)'  id='choice_11_7_2' onchange='gformToggleRadioOther( this )'  tabindex='64'  \/>\n\t\t\t\t\t<label for='choice_11_7_2' id='label_11_7_2' class='gform-field-label gform-field-label--type-inline'>No, I'm not on any of these medications (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_8\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_8\"><legend class='gfield_label gform-field-label'  >If your fitness has deteriorated over the years, how do you explain the fact that you&#039;re in worse shape than when you were younger but haven&#039;t changed your habits at all?<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_11_8'>\n\t\t\t<div class='gchoice gchoice_11_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s my family history (-1)'  id='choice_11_8_0' onchange='gformToggleRadioOther( this )'  tabindex='65'  \/>\n\t\t\t\t\t<label for='choice_11_8_0' id='label_11_8_0' class='gform-field-label gform-field-label--type-inline'>I think it's my family history (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s that I&#039;m less active (+3)'  id='choice_11_8_1' onchange='gformToggleRadioOther( this )'  tabindex='66'  \/>\n\t\t\t\t\t<label for='choice_11_8_1' id='label_11_8_1' class='gform-field-label gform-field-label--type-inline'>I think it's that I'm less active (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s a natural consequence of aging (-1)'  id='choice_11_8_2' onchange='gformToggleRadioOther( this )'  tabindex='67'  \/>\n\t\t\t\t\t<label for='choice_11_8_2' id='label_11_8_2' class='gform-field-label gform-field-label--type-inline'>I think it's a natural consequence of aging (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I don&#039;t know why it&#039;s happening (0)'  id='choice_11_8_3' onchange='gformToggleRadioOther( this )'  tabindex='68'  \/>\n\t\t\t\t\t<label for='choice_11_8_3' id='label_11_8_3' class='gform-field-label gform-field-label--type-inline'>I don't know why it's happening (0)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_9\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_9\"><legend class='gfield_label gform-field-label'  >If you don&#039;t have anyone to exercise with regularly, are you willing to look for a physical activity partner?<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_11_9'>\n\t\t\t<div class='gchoice gchoice_11_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes (+5)'  id='choice_11_9_0' onchange='gformToggleRadioOther( this )'  tabindex='69'  \/>\n\t\t\t\t\t<label for='choice_11_9_0' id='label_11_9_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No (-5)'  id='choice_11_9_1' onchange='gformToggleRadioOther( this )'  tabindex='70'  \/>\n\t\t\t\t\t<label for='choice_11_9_1' id='label_11_9_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_11_11' class='gform_next_button gform-theme-button button' value='Next' tabindex='71' onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_11_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_12\"><legend class='gfield_label gform-field-label'  >Are you willing to join a gym today?<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_11_12'>\n\t\t\t<div class='gchoice gchoice_11_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes (+5)'  id='choice_11_12_0' onchange='gformToggleRadioOther( this )'  tabindex='72'  \/>\n\t\t\t\t\t<label for='choice_11_12_0' id='label_11_12_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No (-5)'  id='choice_11_12_1' onchange='gformToggleRadioOther( this )'  tabindex='73'  \/>\n\t\t\t\t\t<label for='choice_11_12_1' id='label_11_12_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_47\"><legend class='gfield_label gform-field-label'  >If someone told you that you&#039;d need to throw away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your goal, would you do it?<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_11_47'>\n\t\t\t<div class='gchoice gchoice_11_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes (+3)'  id='choice_11_47_0' onchange='gformToggleRadioOther( this )'  tabindex='74'  \/>\n\t\t\t\t\t<label for='choice_11_47_0' id='label_11_47_0' class='gform-field-label gform-field-label--type-inline'>Yes (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No (-3)'  id='choice_11_47_1' onchange='gformToggleRadioOther( this )'  tabindex='75'  \/>\n\t\t\t\t\t<label for='choice_11_47_1' id='label_11_47_1' class='gform-field-label gform-field-label--type-inline'>No (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_14\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_14\"><legend class='gfield_label gform-field-label'  >If an expert presents some information on diet and exercise that contradicts what you currently believe, what approach will you take?<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_11_14'>\n\t\t\t<div class='gchoice gchoice_11_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='keep an open mind and give it a try (+3)'  id='choice_11_14_0' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_11_14_0' id='label_11_14_0' class='gform-field-label gform-field-label--type-inline'>keep an open mind and give it a try (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Ask a friend (O)'  id='choice_11_14_1' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_11_14_1' id='label_11_14_1' class='gform-field-label gform-field-label--type-inline'>Ask a friend (O)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Ignore the advice (-3)'  id='choice_11_14_2' onchange='gformToggleRadioOther( this )'  tabindex='78'  \/>\n\t\t\t\t\t<label for='choice_11_14_2' id='label_11_14_2' class='gform-field-label gform-field-label--type-inline'>Ignore the advice (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_15\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_15\"><legend class='gfield_label gform-field-label'  >Are you willing to have a meeting with your friends and loved ones and share your behavior goals and desired outcomes with them?<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_11_15'>\n\t\t\t<div class='gchoice gchoice_11_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes, right away (+5)'  id='choice_11_15_0' onchange='gformToggleRadioOther( this )'  tabindex='79'  \/>\n\t\t\t\t\t<label for='choice_11_15_0' id='label_11_15_0' class='gform-field-label gform-field-label--type-inline'>Yes, right away (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes, but not just yet (-3)'  id='choice_11_15_1' onchange='gformToggleRadioOther( this )'  tabindex='80'  \/>\n\t\t\t\t\t<label for='choice_11_15_1' id='label_11_15_1' class='gform-field-label gform-field-label--type-inline'>Yes, but not just yet (-3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No (-5)'  id='choice_11_15_2' onchange='gformToggleRadioOther( this )'  tabindex='81'  \/>\n\t\t\t\t\t<label for='choice_11_15_2' id='label_11_15_2' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_16\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_16\"><legend class='gfield_label gform-field-label'  >If your work environment presents significant barriers to you exercising and eating well, would you consider speaking to your employer about changing some of these conditions or are you willing to find new employment?<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_11_16'>\n\t\t\t<div class='gchoice gchoice_11_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes (+5)'  id='choice_11_16_0' onchange='gformToggleRadioOther( this )'  tabindex='82'  \/>\n\t\t\t\t\t<label for='choice_11_16_0' id='label_11_16_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No (-5)'  id='choice_11_16_1' onchange='gformToggleRadioOther( this )'  tabindex='83'  \/>\n\t\t\t\t\t<label for='choice_11_16_1' id='label_11_16_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='84' onclick='jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_17' class='gform_next_button gform-theme-button button' value='Next' tabindex='85' onclick='jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_11_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_18\"><legend class='gfield_label gform-field-label'  >Are you ready to spend less time with people who offer little or no social support for your goals while spending more time with those who do offer support?<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_11_18'>\n\t\t\t<div class='gchoice gchoice_11_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes (+5)'  id='choice_11_18_0' onchange='gformToggleRadioOther( this )'  tabindex='86'  \/>\n\t\t\t\t\t<label for='choice_11_18_0' id='label_11_18_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No (-5)'  id='choice_11_18_1' onchange='gformToggleRadioOther( this )'  tabindex='87'  \/>\n\t\t\t\t\t<label for='choice_11_18_1' id='label_11_18_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_19\"><legend class='gfield_label gform-field-label'  >If a friend or loved one suggests that you don&#039;t have what it takes to get into great shape because you&#039;ve failed before or for some other reason, what will be your response?<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_11_19'>\n\t\t\t<div class='gchoice gchoice_11_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='I can do it (+2)'  id='choice_11_19_0' onchange='gformToggleRadioOther( this )'  tabindex='88'  \/>\n\t\t\t\t\t<label for='choice_11_19_0' id='label_11_19_0' class='gform-field-label gform-field-label--type-inline'>I can do it (+2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='I know I&#039;ve got to make some changes but I&#039;ll take it one day at a time (+5)'  id='choice_11_19_1' onchange='gformToggleRadioOther( this )'  tabindex='89'  \/>\n\t\t\t\t\t<label for='choice_11_19_1' id='label_11_19_1' class='gform-field-label gform-field-label--type-inline'>I know I've got to make some changes but I'll take it one day at a time (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Maybe I can&#039;t do it (-5)'  id='choice_11_19_2' onchange='gformToggleRadioOther( this )'  tabindex='90'  \/>\n\t\t\t\t\t<label for='choice_11_19_2' id='label_11_19_2' class='gform-field-label gform-field-label--type-inline'>Maybe I can't do it (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_20\"><legend class='gfield_label gform-field-label'  >Are you willing to wake up in the morning a bit earlier and stay up at night a bit later to accomplish your goals?<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_11_20'>\n\t\t\t<div class='gchoice gchoice_11_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes (+5)'  id='choice_11_20_0' onchange='gformToggleRadioOther( this )'  tabindex='91'  \/>\n\t\t\t\t\t<label for='choice_11_20_0' id='label_11_20_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No (-5)'  id='choice_11_20_1' onchange='gformToggleRadioOther( this )'  tabindex='92'  \/>\n\t\t\t\t\t<label for='choice_11_20_1' id='label_11_20_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_21\"><legend class='gfield_label gform-field-label'  >Are you willing to slowly work up to five hours of physical activity each week?<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_11_21'>\n\t\t\t<div class='gchoice gchoice_11_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes (+5)'  id='choice_11_21_0' onchange='gformToggleRadioOther( this )'  tabindex='93'  \/>\n\t\t\t\t\t<label for='choice_11_21_0' id='label_11_21_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No (-5)'  id='choice_11_21_1' onchange='gformToggleRadioOther( this )'  tabindex='94'  \/>\n\t\t\t\t\t<label for='choice_11_21_1' id='label_11_21_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_22\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_22\"><label class='gfield_label gform-field-label' for='input_11_22' >How would you rate your quality of sleep out of 10?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_11_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_22\" tabindex='95'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_11_22'>10 = great. 1 = poor<\/div><\/div><div id=\"field_11_23\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_23\"><label class='gfield_label gform-field-label' for='input_11_23' >Do you have trouble getting to bed at night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_11_23' type='text' value='' class='large'   tabindex='96'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_24\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_24\"><label class='gfield_label gform-field-label' for='input_11_24' >Is your sleep broken?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_11_24' type='text' value='' class='large'   tabindex='97'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_25\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_25\"><label class='gfield_label gform-field-label' for='input_11_25' >How many hours do you get of sleep each night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_11_25' type='text' value='' class='large'   tabindex='98'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='99' onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_26' class='gform_next_button gform-theme-button button' value='Next' tabindex='100' onclick='jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_4' class='gform_page flex-fields' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_11_28\"  class=\"gfield gfield--type-html full-width heading-design gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_28\"><h3>What foods did you eat often as a child?<\/h3>\n<p>Recall as best as you can<\/p><\/div><div id=\"field_11_34\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_34\"><label class='gfield_label gform-field-label' for='input_11_34' >Breakfast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_11_34' type='text' value='' class='large'   tabindex='101'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_35\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_35\"><label class='gfield_label gform-field-label' for='input_11_35' >Lunch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_11_35' type='text' value='' class='large'   tabindex='102'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_30\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_30\"><label class='gfield_label gform-field-label' for='input_11_30' >Dinner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_11_30' type='text' value='' class='large'   tabindex='103'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_37\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_37\"><label class='gfield_label gform-field-label' for='input_11_37' >Snacks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_11_37' type='text' value='' class='large'   tabindex='104'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_32\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_32\"><label class='gfield_label gform-field-label' for='input_11_32' >Liquids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_11_32' type='text' value='' class='large'   tabindex='105'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_33\"  class=\"gfield gfield--type-html full-width heading-design gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_33\"><h3>What is your food like these days?<\/h3>\n<p>Describe an average day<\/p><\/div><div id=\"field_11_27\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_27\"><label class='gfield_label gform-field-label' for='input_11_27' >Breakfast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_11_27' type='text' value='' class='large'   tabindex='106'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_29\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_29\"><label class='gfield_label gform-field-label' for='input_11_29' >Lunch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_11_29' type='text' value='' class='large'   tabindex='107'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_36\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_36\"><label class='gfield_label gform-field-label' for='input_11_36' >Dinner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_11_36' type='text' value='' class='large'   tabindex='108'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_42\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_42\"><label class='gfield_label gform-field-label' for='input_11_42' >Snacks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_11_42' type='text' value='' class='large'   tabindex='109'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_38\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_38\"><label class='gfield_label gform-field-label' for='input_11_38' >Liquids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_11_38' type='text' value='' class='large'   tabindex='110'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_11_39\"  class=\"gfield gfield--type-radio gfield--type-choice full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_39\"><legend class='gfield_label gform-field-label'  >Will family and\/or friends be supportive of your desire to make food and\/or lifestyle changes?<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_11_39'>\n\t\t\t<div class='gchoice gchoice_11_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_11_39_0' onchange='gformToggleRadioOther( this )'  tabindex='111'  \/>\n\t\t\t\t\t<label for='choice_11_39_0' id='label_11_39_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_11_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_11_39_1' onchange='gformToggleRadioOther( this )'  tabindex='112'  \/>\n\t\t\t\t\t<label for='choice_11_39_1' id='label_11_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_40\"  class=\"gfield gfield--type-radio gfield--type-choice full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_40\"><legend class='gfield_label gform-field-label'  >Do you cook?<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_11_40'>\n\t\t\t<div class='gchoice gchoice_11_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_11_40_0' onchange='gformToggleRadioOther( this )'  tabindex='113'  \/>\n\t\t\t\t\t<label for='choice_11_40_0' id='label_11_40_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_11_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_11_40_1' onchange='gformToggleRadioOther( this )'  tabindex='114'  \/>\n\t\t\t\t\t<label for='choice_11_40_1' id='label_11_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_31\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_31\"><label class='gfield_label gform-field-label' for='input_11_31' >What percentage of your food is home cooked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_11_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_31\" tabindex='115'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_11_31'>Please enter a number from 0 to 100<\/div><\/div><div id=\"field_11_43\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_43\"><label class='gfield_label gform-field-label' for='input_11_43' >Where do you get the rest from?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_11_43' type='text' value='' class='large'   tabindex='116'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_11_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_44\"><legend class='gfield_label gform-field-label'  >Do you crave sugar, coffee, cigarettes, alcohol or have any major addictions?<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_11_44'>\n\t\t\t<div class='gchoice gchoice_11_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_11_44_0' onchange='gformToggleRadioOther( this )'  tabindex='117'  \/>\n\t\t\t\t\t<label for='choice_11_44_0' id='label_11_44_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_11_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_11_44_1' onchange='gformToggleRadioOther( this )'  tabindex='118'  \/>\n\t\t\t\t\t<label for='choice_11_44_1' id='label_11_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_48\"><legend class='gfield_label gform-field-label'  >Are you willing to commit to the process for the next 6 months?<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_11_48'>\n\t\t\t<div class='gchoice gchoice_11_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_11_48_0' onchange='gformToggleRadioOther( this )'  tabindex='119'  \/>\n\t\t\t\t\t<label for='choice_11_48_0' id='label_11_48_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_11_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_11_48_1' onchange='gformToggleRadioOther( this )'  tabindex='120'  \/>\n\t\t\t\t\t<label for='choice_11_48_1' id='label_11_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_45\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_45\"><label class='gfield_label gform-field-label' for='input_11_45' >The most important thing I should change about my diet to improve my health is<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_11_45' type='text' value='' class='large'   tabindex='121'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_46\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_46\"><label class='gfield_label gform-field-label' for='input_11_46' >Anything else you would like to share?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_11_46' type='text' value='' class='large'   tabindex='122'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_49\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_49\"><label class='gfield_label gform-field-label' for='input_11_49' >Comments<\/label><div class='ginput_container'><input name='input_49' id='input_11_49' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_11_49'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_11' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='123' onclick='if(window[\"gf_submitting_11\"]){return false;}  window[\"gf_submitting_11\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_11\"]){return false;} window[\"gf_submitting_11\"]=true;  jQuery(\"#gform_11\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_11' class='gform_button button' value='Submit' tabindex='124' onclick='if(window[\"gf_submitting_11\"]){return false;}  window[\"gf_submitting_11\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_11\"]){return false;} window[\"gf_submitting_11\"]=true;  jQuery(\"#gform_11\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=11&amp;title=&amp;description=&amp;tabindex=49' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_11' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='11' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_11' value='WyJbXSIsImVmMDA1Y2IwNWIyMDBkM2YyYTgwMjg4YWE3OWJmZDM5Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_11' id='gform_target_page_number_11' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_11' id='gform_source_page_number_11' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_11' id='gform_ajax_frame_11' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 11, 'https:\/\/teamimpaact.com.au\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_11').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_11');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_11').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_11').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_11').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_11').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_11').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_11').val();gformInitSpinner( 11, 'https:\/\/teamimpaact.com.au\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [11, current_page]);window['gf_submitting_11'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_11').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_11').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [11]);window['gf_submitting_11'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_11').text());}, 50);}else{jQuery('#gform_11').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [11, current_page]);} );} ); \n\/* ]]> *\/\n<\/script>\n[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='1' id='gform_wrapper_11' ><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div>\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' target='gform_ajax_frame_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/2392#gf_11' data-formid='11' >\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' >\n                                    <div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_11_1\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_1\"><h2>Readiness for Change<\/h2>\n<p><\/p><\/div><fieldset id=\"field_11_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_2\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_11_2'>\n                            \n                            <span id='input_11_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_11_2_3' value='' tabindex='50'  aria-required='true'     \/>\n                                                    <label for='input_11_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_11_2_6' value='' tabindex='52'  aria-required='true'     \/>\n                                                    <label for='input_11_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_11_3\"  class=\"gfield gfield--type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_3\"><label class='gfield_label gform-field-label' for='input_11_3' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_11_3' type='text' value='' class='large' tabindex='54'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_4\"  class=\"gfield gfield--type-phone gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_4\"><label class='gfield_label gform-field-label' for='input_11_4' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_11_4' type='text' value='' class='large' tabindex='55'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_5\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_5\"><legend class='gfield_label gform-field-label'  >Do you look in the mirror and feel Frustrated, upset, or humiliated because of how your body looks?<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_11_5'>\n\t\t\t<div class='gchoice gchoice_11_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes (+3)'  id='choice_11_5_0' onchange='gformToggleRadioOther( this )'  tabindex='56'  \/>\n\t\t\t\t\t<label for='choice_11_5_0' id='label_11_5_0' class='gform-field-label gform-field-label--type-inline'>Yes (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='I&#039;m not sure (0)'  id='choice_11_5_1' onchange='gformToggleRadioOther( this )'  tabindex='57'  \/>\n\t\t\t\t\t<label for='choice_11_5_1' id='label_11_5_1' class='gform-field-label gform-field-label--type-inline'>I'm not sure (0)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No (-3)'  id='choice_11_5_2' onchange='gformToggleRadioOther( this )'  tabindex='58'  \/>\n\t\t\t\t\t<label for='choice_11_5_2' id='label_11_5_2' class='gform-field-label gform-field-label--type-inline'>No (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_6\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_6\"><legend class='gfield_label gform-field-label'  >When you feel run down and tired, what do you think is the source of these feelings?<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_11_6'>\n\t\t\t<div class='gchoice gchoice_11_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Getting older (-1)'  id='choice_11_6_0' onchange='gformToggleRadioOther( this )'  tabindex='59'  \/>\n\t\t\t\t\t<label for='choice_11_6_0' id='label_11_6_0' class='gform-field-label gform-field-label--type-inline'>Getting older (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='My lifestyle choices (+3)'  id='choice_11_6_1' onchange='gformToggleRadioOther( this )'  tabindex='60'  \/>\n\t\t\t\t\t<label for='choice_11_6_1' id='label_11_6_1' class='gform-field-label gform-field-label--type-inline'>My lifestyle choices (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Something else altogether (-3)'  id='choice_11_6_2' onchange='gformToggleRadioOther( this )'  tabindex='61'  \/>\n\t\t\t\t\t<label for='choice_11_6_2' id='label_11_6_2' class='gform-field-label gform-field-label--type-inline'>Something else altogether (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_7\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_7\"><legend class='gfield_label gform-field-label'  >Are you taking any medications for heart disease, high blood pressure, or type Il diabetes that you didn&#039;t have to take when you were younger?<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_11_7'>\n\t\t\t<div class='gchoice gchoice_11_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes, I&#039;m on two or more of these medications (+3)'  id='choice_11_7_0' onchange='gformToggleRadioOther( this )'  tabindex='62'  \/>\n\t\t\t\t\t<label for='choice_11_7_0' id='label_11_7_0' class='gform-field-label gform-field-label--type-inline'>Yes, I'm on two or more of these medications (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes, I&#039;m on only one of these medications (+1)'  id='choice_11_7_1' onchange='gformToggleRadioOther( this )'  tabindex='63'  \/>\n\t\t\t\t\t<label for='choice_11_7_1' id='label_11_7_1' class='gform-field-label gform-field-label--type-inline'>Yes, I'm on only one of these medications (+1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No, I&#039;m not on any of these medications (-3)'  id='choice_11_7_2' onchange='gformToggleRadioOther( this )'  tabindex='64'  \/>\n\t\t\t\t\t<label for='choice_11_7_2' id='label_11_7_2' class='gform-field-label gform-field-label--type-inline'>No, I'm not on any of these medications (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_8\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_8\"><legend class='gfield_label gform-field-label'  >If your fitness has deteriorated over the years, how do you explain the fact that you&#039;re in worse shape than when you were younger but haven&#039;t changed your habits at all?<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_11_8'>\n\t\t\t<div class='gchoice gchoice_11_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s my family history (-1)'  id='choice_11_8_0' onchange='gformToggleRadioOther( this )'  tabindex='65'  \/>\n\t\t\t\t\t<label for='choice_11_8_0' id='label_11_8_0' class='gform-field-label gform-field-label--type-inline'>I think it's my family history (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s that I&#039;m less active (+3)'  id='choice_11_8_1' onchange='gformToggleRadioOther( this )'  tabindex='66'  \/>\n\t\t\t\t\t<label for='choice_11_8_1' id='label_11_8_1' class='gform-field-label gform-field-label--type-inline'>I think it's that I'm less active (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I think it&#039;s a natural consequence of aging (-1)'  id='choice_11_8_2' onchange='gformToggleRadioOther( this )'  tabindex='67'  \/>\n\t\t\t\t\t<label for='choice_11_8_2' id='label_11_8_2' class='gform-field-label gform-field-label--type-inline'>I think it's a natural consequence of aging (-1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I don&#039;t know why it&#039;s happening (0)'  id='choice_11_8_3' onchange='gformToggleRadioOther( this )'  tabindex='68'  \/>\n\t\t\t\t\t<label for='choice_11_8_3' id='label_11_8_3' class='gform-field-label gform-field-label--type-inline'>I don't know why it's happening (0)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_9\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_9\"><legend class='gfield_label gform-field-label'  >If you don&#039;t have anyone to exercise with regularly, are you willing to look for a physical activity partner?<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_11_9'>\n\t\t\t<div class='gchoice gchoice_11_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes (+5)'  id='choice_11_9_0' onchange='gformToggleRadioOther( this )'  tabindex='69'  \/>\n\t\t\t\t\t<label for='choice_11_9_0' id='label_11_9_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No (-5)'  id='choice_11_9_1' onchange='gformToggleRadioOther( this )'  tabindex='70'  \/>\n\t\t\t\t\t<label for='choice_11_9_1' id='label_11_9_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_11_11' class='gform_next_button gform-theme-button button' value='Next' tabindex='71' onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_11_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_12\"><legend class='gfield_label gform-field-label'  >Are you willing to join a gym today?<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_11_12'>\n\t\t\t<div class='gchoice gchoice_11_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes (+5)'  id='choice_11_12_0' onchange='gformToggleRadioOther( this )'  tabindex='72'  \/>\n\t\t\t\t\t<label for='choice_11_12_0' id='label_11_12_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No (-5)'  id='choice_11_12_1' onchange='gformToggleRadioOther( this )'  tabindex='73'  \/>\n\t\t\t\t\t<label for='choice_11_12_1' id='label_11_12_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_47\"><legend class='gfield_label gform-field-label'  >If someone told you that you&#039;d need to throw away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your goal, would you do it?<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_11_47'>\n\t\t\t<div class='gchoice gchoice_11_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes (+3)'  id='choice_11_47_0' onchange='gformToggleRadioOther( this )'  tabindex='74'  \/>\n\t\t\t\t\t<label for='choice_11_47_0' id='label_11_47_0' class='gform-field-label gform-field-label--type-inline'>Yes (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No (-3)'  id='choice_11_47_1' onchange='gformToggleRadioOther( this )'  tabindex='75'  \/>\n\t\t\t\t\t<label for='choice_11_47_1' id='label_11_47_1' class='gform-field-label gform-field-label--type-inline'>No (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_14\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_14\"><legend class='gfield_label gform-field-label'  >If an expert presents some information on diet and exercise that contradicts what you currently believe, what approach will you take?<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_11_14'>\n\t\t\t<div class='gchoice gchoice_11_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='keep an open mind and give it a try (+3)'  id='choice_11_14_0' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_11_14_0' id='label_11_14_0' class='gform-field-label gform-field-label--type-inline'>keep an open mind and give it a try (+3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Ask a friend (O)'  id='choice_11_14_1' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_11_14_1' id='label_11_14_1' class='gform-field-label gform-field-label--type-inline'>Ask a friend (O)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Ignore the advice (-3)'  id='choice_11_14_2' onchange='gformToggleRadioOther( this )'  tabindex='78'  \/>\n\t\t\t\t\t<label for='choice_11_14_2' id='label_11_14_2' class='gform-field-label gform-field-label--type-inline'>Ignore the advice (-3)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_15\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_15\"><legend class='gfield_label gform-field-label'  >Are you willing to have a meeting with your friends and loved ones and share your behavior goals and desired outcomes with them?<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_11_15'>\n\t\t\t<div class='gchoice gchoice_11_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes, right away (+5)'  id='choice_11_15_0' onchange='gformToggleRadioOther( this )'  tabindex='79'  \/>\n\t\t\t\t\t<label for='choice_11_15_0' id='label_11_15_0' class='gform-field-label gform-field-label--type-inline'>Yes, right away (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes, but not just yet (-3)'  id='choice_11_15_1' onchange='gformToggleRadioOther( this )'  tabindex='80'  \/>\n\t\t\t\t\t<label for='choice_11_15_1' id='label_11_15_1' class='gform-field-label gform-field-label--type-inline'>Yes, but not just yet (-3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No (-5)'  id='choice_11_15_2' onchange='gformToggleRadioOther( this )'  tabindex='81'  \/>\n\t\t\t\t\t<label for='choice_11_15_2' id='label_11_15_2' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_16\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_16\"><legend class='gfield_label gform-field-label'  >If your work environment presents significant barriers to you exercising and eating well, would you consider speaking to your employer about changing some of these conditions or are you willing to find new employment?<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_11_16'>\n\t\t\t<div class='gchoice gchoice_11_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes (+5)'  id='choice_11_16_0' onchange='gformToggleRadioOther( this )'  tabindex='82'  \/>\n\t\t\t\t\t<label for='choice_11_16_0' id='label_11_16_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No (-5)'  id='choice_11_16_1' onchange='gformToggleRadioOther( this )'  tabindex='83'  \/>\n\t\t\t\t\t<label for='choice_11_16_1' id='label_11_16_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='84' onclick='jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_17' class='gform_next_button gform-theme-button button' value='Next' tabindex='85' onclick='jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_11_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_18\"><legend class='gfield_label gform-field-label'  >Are you ready to spend less time with people who offer little or no social support for your goals while spending more time with those who do offer support?<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_11_18'>\n\t\t\t<div class='gchoice gchoice_11_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes (+5)'  id='choice_11_18_0' onchange='gformToggleRadioOther( this )'  tabindex='86'  \/>\n\t\t\t\t\t<label for='choice_11_18_0' id='label_11_18_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No (-5)'  id='choice_11_18_1' onchange='gformToggleRadioOther( this )'  tabindex='87'  \/>\n\t\t\t\t\t<label for='choice_11_18_1' id='label_11_18_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_19\"><legend class='gfield_label gform-field-label'  >If a friend or loved one suggests that you don&#039;t have what it takes to get into great shape because you&#039;ve failed before or for some other reason, what will be your response?<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_11_19'>\n\t\t\t<div class='gchoice gchoice_11_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='I can do it (+2)'  id='choice_11_19_0' onchange='gformToggleRadioOther( this )'  tabindex='88'  \/>\n\t\t\t\t\t<label for='choice_11_19_0' id='label_11_19_0' class='gform-field-label gform-field-label--type-inline'>I can do it (+2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='I know I&#039;ve got to make some changes but I&#039;ll take it one day at a time (+5)'  id='choice_11_19_1' onchange='gformToggleRadioOther( this )'  tabindex='89'  \/>\n\t\t\t\t\t<label for='choice_11_19_1' id='label_11_19_1' class='gform-field-label gform-field-label--type-inline'>I know I've got to make some changes but I'll take it one day at a time (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Maybe I can&#039;t do it (-5)'  id='choice_11_19_2' onchange='gformToggleRadioOther( this )'  tabindex='90'  \/>\n\t\t\t\t\t<label for='choice_11_19_2' id='label_11_19_2' class='gform-field-label gform-field-label--type-inline'>Maybe I can't do it (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_20\"><legend class='gfield_label gform-field-label'  >Are you willing to wake up in the morning a bit earlier and stay up at night a bit later to accomplish your goals?<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_11_20'>\n\t\t\t<div class='gchoice gchoice_11_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes (+5)'  id='choice_11_20_0' onchange='gformToggleRadioOther( this )'  tabindex='91'  \/>\n\t\t\t\t\t<label for='choice_11_20_0' id='label_11_20_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No (-5)'  id='choice_11_20_1' onchange='gformToggleRadioOther( this )'  tabindex='92'  \/>\n\t\t\t\t\t<label for='choice_11_20_1' id='label_11_20_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_21\"><legend class='gfield_label gform-field-label'  >Are you willing to slowly work up to five hours of physical activity each week?<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_11_21'>\n\t\t\t<div class='gchoice gchoice_11_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes (+5)'  id='choice_11_21_0' onchange='gformToggleRadioOther( this )'  tabindex='93'  \/>\n\t\t\t\t\t<label for='choice_11_21_0' id='label_11_21_0' class='gform-field-label gform-field-label--type-inline'>Yes (+5)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No (-5)'  id='choice_11_21_1' onchange='gformToggleRadioOther( this )'  tabindex='94'  \/>\n\t\t\t\t\t<label for='choice_11_21_1' id='label_11_21_1' class='gform-field-label gform-field-label--type-inline'>No (-5)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_22\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_22\"><label class='gfield_label gform-field-label' for='input_11_22' >How would you rate your quality of sleep out of 10?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_11_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_22\" tabindex='95'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_11_22'>10 = great. 1 = poor<\/div><\/div><div id=\"field_11_23\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_23\"><label class='gfield_label gform-field-label' for='input_11_23' >Do you have trouble getting to bed at night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_11_23' type='text' value='' class='large'   tabindex='96'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_24\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_24\"><label class='gfield_label gform-field-label' for='input_11_24' >Is your sleep broken?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_11_24' type='text' value='' class='large'   tabindex='97'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_25\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_25\"><label class='gfield_label gform-field-label' for='input_11_25' >How many hours do you get of sleep each night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_11_25' type='text' value='' class='large'   tabindex='98'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='99' onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_26' class='gform_next_button gform-theme-button button' value='Next' tabindex='100' onclick='jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_4' class='gform_page flex-fields' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_11_28\"  class=\"gfield gfield--type-html full-width heading-design gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_28\"><h3>What foods did you eat often as a child?<\/h3>\n<p>Recall as best as you can<\/p><\/div><div id=\"field_11_34\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_34\"><label class='gfield_label gform-field-label' for='input_11_34' >Breakfast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_11_34' type='text' value='' class='large'   tabindex='101'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_35\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_35\"><label class='gfield_label gform-field-label' for='input_11_35' >Lunch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_11_35' type='text' value='' class='large'   tabindex='102'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_30\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_30\"><label class='gfield_label gform-field-label' for='input_11_30' >Dinner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_11_30' type='text' value='' class='large'   tabindex='103'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_37\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_37\"><label class='gfield_label gform-field-label' for='input_11_37' >Snacks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_11_37' type='text' value='' class='large'   tabindex='104'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_32\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_32\"><label class='gfield_label gform-field-label' for='input_11_32' >Liquids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_11_32' type='text' value='' class='large'   tabindex='105'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_33\"  class=\"gfield gfield--type-html full-width heading-design gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_33\"><h3>What is your food like these days?<\/h3>\n<p>Describe an average day<\/p><\/div><div id=\"field_11_27\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_27\"><label class='gfield_label gform-field-label' for='input_11_27' >Breakfast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_11_27' type='text' value='' class='large'   tabindex='106'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_29\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_29\"><label class='gfield_label gform-field-label' for='input_11_29' >Lunch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_11_29' type='text' value='' class='large'   tabindex='107'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_36\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_36\"><label class='gfield_label gform-field-label' for='input_11_36' >Dinner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_11_36' type='text' value='' class='large'   tabindex='108'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_42\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_42\"><label class='gfield_label gform-field-label' for='input_11_42' >Snacks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_11_42' type='text' value='' class='large'   tabindex='109'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_38\"  class=\"gfield gfield--type-text gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_38\"><label class='gfield_label gform-field-label' for='input_11_38' >Liquids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_11_38' type='text' value='' class='large'   tabindex='110'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_11_39\"  class=\"gfield gfield--type-radio gfield--type-choice full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_39\"><legend class='gfield_label gform-field-label'  >Will family and\/or friends be supportive of your desire to make food and\/or lifestyle changes?<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_11_39'>\n\t\t\t<div class='gchoice gchoice_11_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_11_39_0' onchange='gformToggleRadioOther( this )'  tabindex='111'  \/>\n\t\t\t\t\t<label for='choice_11_39_0' id='label_11_39_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_11_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_11_39_1' onchange='gformToggleRadioOther( this )'  tabindex='112'  \/>\n\t\t\t\t\t<label for='choice_11_39_1' id='label_11_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_40\"  class=\"gfield gfield--type-radio gfield--type-choice full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_40\"><legend class='gfield_label gform-field-label'  >Do you cook?<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_11_40'>\n\t\t\t<div class='gchoice gchoice_11_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_11_40_0' onchange='gformToggleRadioOther( this )'  tabindex='113'  \/>\n\t\t\t\t\t<label for='choice_11_40_0' id='label_11_40_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_11_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_11_40_1' onchange='gformToggleRadioOther( this )'  tabindex='114'  \/>\n\t\t\t\t\t<label for='choice_11_40_1' id='label_11_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_31\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_31\"><label class='gfield_label gform-field-label' for='input_11_31' >What percentage of your food is home cooked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_11_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_31\" tabindex='115'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_11_31'>Please enter a number from 0 to 100<\/div><\/div><div id=\"field_11_43\"  class=\"gfield gfield--type-text full-width gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_43\"><label class='gfield_label gform-field-label' for='input_11_43' >Where do you get the rest from?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_11_43' type='text' value='' class='large'   tabindex='116'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_11_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_44\"><legend class='gfield_label gform-field-label'  >Do you crave sugar, coffee, cigarettes, alcohol or have any major addictions?<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_11_44'>\n\t\t\t<div class='gchoice gchoice_11_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_11_44_0' onchange='gformToggleRadioOther( this )'  tabindex='117'  \/>\n\t\t\t\t\t<label for='choice_11_44_0' id='label_11_44_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_11_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_11_44_1' onchange='gformToggleRadioOther( this )'  tabindex='118'  \/>\n\t\t\t\t\t<label for='choice_11_44_1' id='label_11_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_11_48\"><legend class='gfield_label gform-field-label'  >Are you willing to commit to the process for the next 6 months?<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_11_48'>\n\t\t\t<div class='gchoice gchoice_11_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_11_48_0' onchange='gformToggleRadioOther( this )'  tabindex='119'  \/>\n\t\t\t\t\t<label for='choice_11_48_0' id='label_11_48_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_11_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_11_48_1' onchange='gformToggleRadioOther( this )'  tabindex='120'  \/>\n\t\t\t\t\t<label for='choice_11_48_1' id='label_11_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_45\"  class=\"gfield gfield--type-text full-width 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