{"id":1043,"date":"2025-02-18T17:09:03","date_gmt":"2025-02-18T17:09:03","guid":{"rendered":"https:\/\/laserandstop.com\/?page_id=1043"},"modified":"2025-05-20T17:56:18","modified_gmt":"2025-05-20T17:56:18","slug":"%d1%82%d0%b5%d1%81%d1%82-%d0%bd%d0%b0-%d0%bf%d1%80%d0%b8%d0%b3%d0%be%d0%b4%d0%bd%d0%be%d1%81%d1%82%d1%8c-%d0%ba-%d0%b0%d1%83%d1%80%d0%b8%d0%ba%d1%83%d0%bb%d0%be%d1%82%d0%b5%d1%80%d0%b0%d0%bf%d0%b8","status":"publish","type":"page","link":"https:\/\/laserandstop.com\/ru\/%d1%82%d0%b5%d1%81%d1%82-%d0%bd%d0%b0-%d0%bf%d1%80%d0%b8%d0%b3%d0%be%d0%b4%d0%bd%d0%be%d1%81%d1%82%d1%8c-%d0%ba-%d0%b0%d1%83%d1%80%d0%b8%d0%ba%d1%83%d0%bb%d0%be%d1%82%d0%b5%d1%80%d0%b0%d0%bf%d0%b8\/","title":{"rendered":"\u0422\u0435\u0441\u0442 \u043d\u0430 \u043f\u0440\u0438\u0433\u043e\u0434\u043d\u043e\u0441\u0442\u044c \u043a \u0430\u0443\u0440\u0438\u043a\u0443\u043b\u043e\u0442\u0435\u0440\u0430\u043f\u0438\u0438"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1043\" class=\"elementor elementor-1043\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5fe2a41a e-flex e-con-boxed e-con e-parent\" data-id=\"5fe2a41a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-139d9929 elementor-widget elementor-widget-text-editor\" data-id=\"139d9929\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'>\n<form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ff_calc_form ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" >\n<fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n<legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Blank Form (#4)<\/legend>\n<p><input type='hidden' name='__fluent_form_embded_post_id' value='1043' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"a3122caae8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ru\/wp-json\/wp\/v2\/pages\/1043\" \/><\/p>\n<div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_1\" >\n<h2>Laser Auriculotherapy Eligibility Questionnaire For Tobacco<\/h2>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"1. How long have you been smoking?\">1. How long have you been smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_50f705ccc95a0ca56c45369d4bda7226'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Less than 1 year\" data-calc_value=\"10\"  id='input_radio_50f705ccc95a0ca56c45369d4bda7226' aria-label='Less than 1 year' aria-invalid='false' aria-required=true> <span>Less than 1 year<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_08421d0accf003db73c5fea27e0a8875'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1 to 5 years\" data-calc_value=\"7\"  id='input_radio_08421d0accf003db73c5fea27e0a8875' aria-label='1 to 5 years' aria-invalid='false' aria-required=true> <span>1 to 5 years<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_29dbdd475045e2496c74bdec158122bf'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"More than 5 years \" data-calc_value=\"4\"  id='input_radio_29dbdd475045e2496c74bdec158122bf' aria-label='More than 5 years' aria-invalid='false' aria-required=true> <span>More than 5 years <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"2. How many cigarettes do you smoke per day on average?\">2. How many cigarettes do you smoke per day on average?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_ff816a9895a7cb3f9c8fb40137fee7ca'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Less than 5\" data-calc_value=\"10\"  id='input_radio_1_ff816a9895a7cb3f9c8fb40137fee7ca' aria-label='Less than 5' aria-invalid='false' aria-required=true> <span>Less than 5<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_bc8c7f559becb3319f959c2fde0efed8'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"5 to 10\" data-calc_value=\"8\"  id='input_radio_1_bc8c7f559becb3319f959c2fde0efed8' aria-label='5 to 10' aria-invalid='false' aria-required=true> <span>5 to 10<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_c8fee25991aafcb8ee45b2627189377a'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"11 to 20 \" data-calc_value=\"5\"  id='input_radio_1_c8fee25991aafcb8ee45b2627189377a' aria-label='11 to 20' aria-invalid='false' aria-required=true> <span>11 to 20 <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_37bb731997d4716636841c60ab5fbc9d'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"More than 20\" data-calc_value=\"2\"  id='input_radio_1_37bb731997d4716636841c60ab5fbc9d' aria-label='More than 20' aria-invalid='false' aria-required=true> <span>More than 20<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"3. Have you tried to quit smoking before?\">3. Have you tried to quit smoking before?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_dcc831e4d88f4300f46ec6573f83b7d3'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, multiple times \" data-calc_value=\"8\"  id='input_radio_2_dcc831e4d88f4300f46ec6573f83b7d3' aria-label='Yes, multiple times' aria-invalid='false' aria-required=true> <span>Yes, multiple times <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_0be9da2504249363931fa2e9ea502884'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, once\" data-calc_value=\"6\"  id='input_radio_2_0be9da2504249363931fa2e9ea502884' aria-label='Yes, once' aria-invalid='false' aria-required=true> <span>Yes, once<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_1e26bbc2ea2176c2db7f2e815b562e85'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No \" data-calc_value=\"4\"  id='input_radio_2_1e26bbc2ea2176c2db7f2e815b562e85' aria-label='No' aria-invalid='false' aria-required=true> <span>No <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"4. If yes, how long did you stay smoke-free?\">4. If yes, how long did you stay smoke-free?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_30cbe2aa83ca9e27d5acd5d1e1a9cb12'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"More than 6 months \" data-calc_value=\"10\"  id='input_radio_3_30cbe2aa83ca9e27d5acd5d1e1a9cb12' aria-label='More than 6 months' aria-invalid='false' aria-required=true> <span>More than 6 months <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_c53dea86909562b12e9c1d4b6e96f60c'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1 to 6 months \" data-calc_value=\"7\"  id='input_radio_3_c53dea86909562b12e9c1d4b6e96f60c' aria-label='1 to 6 months' aria-invalid='false' aria-required=true> <span>1 to 6 months <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_08d7f1d50ac2a13ab9736263a1305d12'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Less than a month \" data-calc_value=\"4\"  id='input_radio_3_08d7f1d50ac2a13ab9736263a1305d12' aria-label='Less than a month' aria-invalid='false' aria-required=true> <span>Less than a month <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_8baa4dad44e4ba9346a2aba0725a6a21'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No attempts \" data-calc_value=\"2\"  id='input_radio_3_8baa4dad44e4ba9346a2aba0725a6a21' aria-label='No attempts' aria-invalid='false' aria-required=true> <span>No attempts <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"5. What motivates you to quit smoking today?\">5. What motivates you to quit smoking today?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_6d1fb50df802d830e6b2662089250175'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Personal health \" data-calc_value=\"10\"  id='input_radio_4_6d1fb50df802d830e6b2662089250175' aria-label='Personal health' aria-invalid='false' aria-required=true> <span>Personal health <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_ad5b77ac83e467d1b3734e077227e148'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Family\/Loved ones \" data-calc_value=\"8\"  id='input_radio_4_ad5b77ac83e467d1b3734e077227e148' aria-label='Family\/Loved ones' aria-invalid='false' aria-required=true> <span>Family\/Loved ones <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_50bf3435e7b959ac622353388a4f1a49'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Financial cost \" data-calc_value=\"6\"  id='input_radio_4_50bf3435e7b959ac622353388a4f1a49' aria-label='Financial cost' aria-invalid='false' aria-required=true> <span>Financial cost <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_15bf8179d3f3ab6ea0e6e58f993e7a59'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Social pressure\" data-calc_value=\"4\"  id='input_radio_4_15bf8179d3f3ab6ea0e6e58f993e7a59' aria-label='Social pressure' aria-invalid='false' aria-required=true> <span>Social pressure<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"6. Do you have any personal or family history of heart disease, respiratory diseases (asthma, COPD), or cancer?\">6. Do you have any personal or family history of heart disease, respiratory diseases (asthma, COPD), or cancer?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_249e8bf73b90332a27c0b92a9c695adc'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No \" data-calc_value=\"10\"  id='input_radio_5_249e8bf73b90332a27c0b92a9c695adc' aria-label='No' aria-invalid='false' aria-required=true> <span>No <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_b4524fa0485b77f1c417cac489feb214'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, family history \" data-calc_value=\"6\"  id='input_radio_5_b4524fa0485b77f1c417cac489feb214' aria-label='Yes, family history' aria-invalid='false' aria-required=true> <span>Yes, family history <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_b6066d23bf47ed348fbc73fb20a4f58a'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, personal history \" data-calc_value=\"3\"  id='input_radio_5_b6066d23bf47ed348fbc73fb20a4f58a' aria-label='Yes, personal history' aria-invalid='false' aria-required=true> <span>Yes, personal history <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"7. Do you experience persistent symptoms related to smoking (chronic cough, shortness of breath, chest pain)?\">7. Do you experience persistent symptoms related to smoking (chronic cough, shortness of breath, chest pain)?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_eee9b7d9a16c647ac27a9c73e3491033'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No \" data-calc_value=\"10\"  id='input_radio_6_eee9b7d9a16c647ac27a9c73e3491033' aria-label='No' aria-invalid='false' aria-required=true> <span>No <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_a3de9ba243f7b41f02a75708c790abd5'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, mild\" data-calc_value=\"6\"  id='input_radio_6_a3de9ba243f7b41f02a75708c790abd5' aria-label='Yes, mild' aria-invalid='false' aria-required=true> <span>Yes, mild<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_c911d9f0902612f67357b20737b895b1'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, moderate to severe \" data-calc_value=\"3\"  id='input_radio_6_c911d9f0902612f67357b20737b895b1' aria-label='Yes, moderate to severe' aria-invalid='false' aria-required=true> <span>Yes, moderate to severe <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"8. Are you currently taking any medications that might affect your smoking cessation (antidepressants, anxiolytics, etc.)?\">8. Are you currently taking any medications that might affect your smoking cessation (antidepressants, anxiolytics, etc.)?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_c937a6d2f42a5a2515a7453ac00471d7'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No \" data-calc_value=\"10\"  id='input_radio_7_c937a6d2f42a5a2515a7453ac00471d7' aria-label='No' aria-invalid='false' aria-required=true> <span>No <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_c6ff71af784c2fe22a7d47887e8d53a7'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, but compatible with smoking cessation \" data-calc_value=\"6\"  id='input_radio_7_c6ff71af784c2fe22a7d47887e8d53a7' aria-label='Yes, but compatible with smoking cessation' aria-invalid='false' aria-required=true> <span>Yes, but compatible with smoking cessation <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_57c49a128719c461490cc95362f2107d'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, requires medical advice before quitting smoking \" data-calc_value=\"3\"  id='input_radio_7_57c49a128719c461490cc95362f2107d' aria-label='Yes, requires medical advice before quitting smoking' aria-invalid='false' aria-required=true> <span>Yes, requires medical advice before quitting smoking <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"9. Has your doctor ever advised you to quit smoking for health reasons?\">9. Has your doctor ever advised you to quit smoking for health reasons?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_5d1ace683388a5e3d3f69c8907d65f25'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes \" data-calc_value=\"10\"  id='input_radio_8_5d1ace683388a5e3d3f69c8907d65f25' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_433e1bc3d66454d98bfe77be647b5b2e'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No \" data-calc_value=\"5\"  id='input_radio_8_433e1bc3d66454d98bfe77be647b5b2e' aria-label='No' aria-invalid='false' aria-required=true> <span>No <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_81d578417e8f382d091983cc5249995e'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Haven\u2019t consulted a doctor recently \" data-calc_value=\"3\"  id='input_radio_8_81d578417e8f382d091983cc5249995e' aria-label='Haven\u2019t consulted a doctor recently' aria-invalid='false' aria-required=true> <span>Haven\u2019t consulted a doctor recently <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"10. Do you associate smoking with stress or anxiety management?\">10. Do you associate smoking with stress or anxiety management?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_e0cd00310a4fa49724f68b8b722d71f0'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No, not at all\" data-calc_value=\"10\"  id='input_radio_9_e0cd00310a4fa49724f68b8b722d71f0' aria-label='No, not at all' aria-invalid='false' aria-required=true> <span>No, not at all<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_34967abc61a2f87cbbebd70af615dbce'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Sometimes\" data-calc_value=\"6\"  id='input_radio_9_34967abc61a2f87cbbebd70af615dbce' aria-label='Sometimes' aria-invalid='false' aria-required=true> <span>Sometimes<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_5fc51b1321e84f7c4d3ed3e9f0f282fb'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, very often\" data-calc_value=\"3\"  id='input_radio_9_5fc51b1321e84f7c4d3ed3e9f0f282fb' aria-label='Yes, very often' aria-invalid='false' aria-required=true> <span>Yes, very often<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"11. Are you afraid of gaining weight after quitting smoking?\">11. Are you afraid of gaining weight after quitting smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_b66b88d08958389ef5570a98ca9b543a'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No, not at all\" data-calc_value=\"10\"  id='input_radio_10_b66b88d08958389ef5570a98ca9b543a' aria-label='No, not at all' aria-invalid='false' aria-required=true> <span>No, not at all<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_40f40f00269a3732ec52179077f699c7'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"A little\" data-calc_value=\"6\"  id='input_radio_10_40f40f00269a3732ec52179077f699c7' aria-label='A little' aria-invalid='false' aria-required=true> <span>A little<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_25c076ad1d35e543dfa965f5186b8556'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, a lot\" data-calc_value=\"3\"  id='input_radio_10_25c076ad1d35e543dfa965f5186b8556' aria-label='Yes, a lot' aria-invalid='false' aria-required=true> <span>Yes, a lot<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"12. Do you feel mentally ready to quit smoking?\">12. Do you feel mentally ready to quit smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_6878165061992223186a7e006533c95f'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, absolutely\" data-calc_value=\"10\"  id='input_radio_11_6878165061992223186a7e006533c95f' aria-label='Yes, absolutely' aria-invalid='false' aria-required=true> <span>Yes, absolutely<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_f07dd6a3dc6c5c7e34bc3153ab8eb6e1'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I&#039;m not sure \" data-calc_value=\"5\"  id='input_radio_11_f07dd6a3dc6c5c7e34bc3153ab8eb6e1' aria-label='I&#039;m not sure' aria-invalid='false' aria-required=true> <span>I&#8217;m not sure <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_45b57131c75304e15a6de6d0ecbd827c'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No, not yet\" data-calc_value=\"1\"  id='input_radio_11_45b57131c75304e15a6de6d0ecbd827c' aria-label='No, not yet' aria-invalid='false' aria-required=true> <span>No, not yet<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"13. Are you familiar with auriculotherapy by LLLT laser as a method to quit smoking?\">13. Are you familiar with auriculotherapy by LLLT laser as a method to quit smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_c050afbcc17ed62eb567216c1bbfb383'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, and I am convinced of its effectiveness \" data-calc_value=\"10\"  id='input_radio_12_c050afbcc17ed62eb567216c1bbfb383' aria-label='Yes, and I am convinced of its effectiveness' aria-invalid='false' aria-required=true> <span>Yes, and I am convinced of its effectiveness <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_16182fdc748f38b1eb9b8114d2047af7'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, but I am skeptical \" data-calc_value=\"6\"  id='input_radio_12_16182fdc748f38b1eb9b8114d2047af7' aria-label='Yes, but I am skeptical' aria-invalid='false' aria-required=true> <span>Yes, but I am skeptical <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_2c7af218dd2156360960eb5699e85e66'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No, I don\u2019t know about it\" data-calc_value=\"4\"  id='input_radio_12_2c7af218dd2156360960eb5699e85e66' aria-label='No, I don\u2019t know about it' aria-invalid='false' aria-required=true> <span>No, I don\u2019t know about it<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"14. Are you open to trying alternative or complementary medicine to help you quit smoking?\">14. Are you open to trying alternative or complementary medicine to help you quit smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_7a979021d81c922910a322070e6974e6'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, completely\" data-calc_value=\"10\"  id='input_radio_13_7a979021d81c922910a322070e6974e6' aria-label='Yes, completely' aria-invalid='false' aria-required=true> <span>Yes, completely<\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_517d1a76fdb385fd3ad2d2434ce86f61'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, but with some doubts \" data-calc_value=\"6\"  id='input_radio_13_517d1a76fdb385fd3ad2d2434ce86f61' aria-label='Yes, but with some doubts' aria-invalid='false' aria-required=true> <span>Yes, but with some doubts <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_6ef227b2c879ad8346b77ee01579de6c'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No, I prefer traditional methods\" data-calc_value=\"3\"  id='input_radio_13_6ef227b2c879ad8346b77ee01579de6c' aria-label='No, I prefer traditional methods' aria-invalid='false' aria-required=true> <span>No, I prefer traditional methods<\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"15. Do you think personal motivation is more important than the method used to quit smoking?\">15. Do you think personal motivation is more important than the method used to quit smoking?<\/label><\/div>\n<div class='ff-el-input--content'>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_e9bbe94a8e6b5692018767d8c679698d'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes, I believe it\u2019s mainly about willpower \" data-calc_value=\"10\"  id='input_radio_14_e9bbe94a8e6b5692018767d8c679698d' aria-label='Yes, I believe it\u2019s mainly about willpower' aria-invalid='false' aria-required=true> <span>Yes, I believe it\u2019s mainly about willpower <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_efededb005f0f465605ad3f90a6b538c'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I think the method also plays an important role \" data-calc_value=\"7\"  id='input_radio_14_efededb005f0f465605ad3f90a6b538c' aria-label='I think the method also plays an important role' aria-invalid='false' aria-required=true> <span>I think the method also plays an important role <\/span><\/label><\/div>\n<div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_8af9a2d6016377701114cff0bdd65040'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I rely mainly on the effectiveness of the method \" data-calc_value=\"4\"  id='input_radio_14_8af9a2d6016377701114cff0bdd65040' aria-label='I rely mainly on the effectiveness of the method' aria-invalid='false' aria-required=true> <span>I rely mainly on the effectiveness of the method <\/span><\/label><\/div>\n<\/div>\n<\/div>\n<div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" >\n<div class='ff-t-container'>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_names_1_first_name_' id='label_ff_4_names_1_first_name_' >First Name<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_4_names_1_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_names_1_last_name_' id='label_ff_4_names_1_last_name_' >Last Name<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_4_names_1_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_email_1' id='label_ff_4_email_1' aria-label=\"Email\">Email<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_4_email_1\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=true><\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_phone_3' id='label_ff_4_phone_3' aria-label=\"Phone\/Mobile\">Phone\/Mobile<\/label><\/div>\n<div class='ff-el-input--content'><input name=\"phone_3\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone_3\" id=\"ff_4_phone_3\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_numeric_field' id='label_ff_4_numeric_field' aria-label=\"Score\">Score<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"numeric_field\" id=\"ff_4_numeric_field\" class=\"ff-el-form-control  ff_has_formula\" data-name=\"numeric_field\" data-calculation_formula=\"{radio.input_radio}+{radio.input_radio_1}+{radio.input_radio_2}+{radio.input_radio_3}+{radio.input_radio_4}+{radio.input_radio_5}+{radio.input_radio_6}+{radio.input_radio_7}+{radio.input_radio_8}+{radio.input_radio_9}+{radio.input_radio_10}+{radio.input_radio_11}+{radio.input_radio_12}+{radio.input_radio_13}+{radio.input_radio_14}\" readonly=\"1\"  aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description' id='label_ff_4_description' aria-label=\"Evaluation of Results:\">Evaluation of Results:<\/label><\/div>\n<div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description\" name=\"description\" id=\"ff_4_description\" class=\"ff-el-form-control\" placeholder=\"\ud83d\udd39 130 to 150 Points \u2013 You&#039;re Ready to Succeed! Your motivation and openness to auriculotherapy put you in the best position for success. Now is the perfect time to take action. Book your session today and start your smoke-free journey! \" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div>\n<\/div>\n<div class='ff-el-group ff-el-form-hide_label'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_1' id='label_ff_4_description_1' aria-label=\"Textarea\">Textarea<\/label><\/div>\n<div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_1\" name=\"description_1\" id=\"ff_4_description_1\" class=\"ff-el-form-control\" placeholder=\"\ud83d\udd39 100 to 129 Points \u2013 You\u2019re Almost There! Your motivation is strong, but a little extra support can make all the difference. With the right guidance, you can boost your confidence and maximize your success. Let\u2019s take the next step together!\" rows=\"4\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_2\" name=\"description_2\" id=\"ff_4_description_2\" class=\"ff-el-form-control\" placeholder=\"\ud83d\udd39 70 to 99 Points \u2013 You&#039;re on the Right Track! You have the desire to quit, but some challenges may slow you down. With expert guidance, we can help you overcome obstacles and boost your success. Let\u2019s create a plan together\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div>\n<\/div>\n<div class='ff-el-group ff-el-form-hide_label'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_3' id='label_ff_4_description_3' aria-label=\"Textarea\">Textarea<\/label><\/div>\n<div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_3\" name=\"description_3\" id=\"ff_4_description_3\" class=\"ff-el-form-control\" placeholder=\"\ud83d\udd39 Less than 70 Points \u2013 Let\u2019s Build Your Readiness! Quitting smoking is a big step, and the right preparation is key. We can help strengthen your motivation and explore the best approach for you. Let&#039;s start your journey at your own pace! \" rows=\"3\" cols=\"2\" data-name=\"description_3\" ><\/textarea><\/div>\n<\/div>\n<div class='ff-el-group ff-text-center ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit My Results and Be Contacted\">Submit My Results and Be Contacted<\/button><\/div>\n<\/fieldset>\n<\/form>\n<div id='fluentform_4_errors' class='ff-errors-in-stack ff_form_instance_4_1 ff-form-loading_errors ff_form_instance_4_1_errors'><\/div>\n<\/div>\n<p>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_4_1 = 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