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medical-family-declaration.html
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medical-family-declaration.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Insuredoo - Medical Family Declaration</title>
<meta content="width=device-width, initial-scale=1.0" name="viewport">
<meta content="" name="keywords">
<meta content="" name="description">
<!-- Favicons -->
<link href="img/favicon.png" rel="icon">
<link href="img/apple-touch-icon.png" rel="apple-touch-icon">
<!-- Google Fonts -->
<link href="https://fonts.googleapis.com/css?family=Open+Sans:300,300i,400,400i,500,600,700,700i" rel="stylesheet">
<link href="https://fonts.googleapis.com/css?family=DM+Serif+Text&display=swap" rel="stylesheet">
<!-- Bootstrap CSS File -->
<link href="lib/bootstrap/css/bootstrap.min.css" rel="stylesheet">
<!-- Libraries CSS Files -->
<link href="lib/font-awesome/css/font-awesome.min.css" rel="stylesheet">
<link href="lib/animate/css/animate.min.css" rel="stylesheet">
<link href="lib/owlcarousel/css/owl.carousel.min.css" rel="stylesheet">
<link href="lib/fancybox/css/jquery.fancybox.min.css" rel="stylesheet" />
<link href="lib/form/css/select2.min.css" rel="stylesheet" />
<link href="lib/form/css/select2-bootstrap4.css" rel="stylesheet" />
<link href="lib/tooltip/css/tooltipster.bundle.min.css" rel="stylesheet" />
<link href="lib/tooltip/css/plugins/tooltipster/sideTip/themes/tooltipster-sideTip-light.min.css" rel="stylesheet" />
<!-- Main Stylesheet File -->
<link href="css/style.css" rel="stylesheet">
</head>
<body>
<a href="#" class="need-help-btn wow fadeInRight" data-wow-duration="1.4s"><i class="fa fa-envelope-o"></i> Need help?</a>
<!--==========================
Header
============================-->
<header id="header">
<div class="container-fluid">
<nav class="main-nav float-left d-none d-lg-block">
<ul>
<li><a href="about-insuredoo.html">About Us</a></li>
<li><a href="#products">Products</a></li>
<li><a href="#blog">Blog</a></li>
<li><a href="#claim">Claim</a></li>
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</ul>
</nav>
<!-- .main-nav -->
<div class="logo float-left d-lg-block">
<h1 class="text-center"><a href="index.html" class="scrollto"><img src="img/logo.png" alt="Insuredoo,The Easiest Way To Insure" class="img-fluid"></a></h1>
</div>
<div id="topbar" class="float-right d-lg-block">
<div class="right-menu">
<div class="right-menu-main-div login">
<p class="btn">Login </p>
<div class="login_box_container">
<div class="arrow-up"></div>
<div class="loginformholder">
<form action="index.html" method="post">
<p>
<label for="email_txt">Email</label>
<input type="email" placeholder="[email protected]" name="email_txt" id="email_txt" data-validation="required email" data-validation-error-msg="Please enter a valid email" />
</p>
<p>
<label for="password_txt">Password</label>
<input type="password" name="password_txt" id="password_txt" autocomplete="new-password" data-validation="required" data-validation-error-msg="Please enter your valid password" />
</p>
<input type="submit" value="Login" />
</form>
<div class="other_links"> <a href="#" class="forgot_my_password">Forgot my password</a> <a href="#" class="sign_up">Sign up</a> </div>
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</div>
</div>
</div>
</header>
<!-- #header -->
<!--==========================
Intro Section
============================-->
<main id="medical_insurance">
<!--==========================
Insurance Intro Section
============================-->
<section id="medical_insurance_intro" class="clearfix main_section">
<div class="container">
<header class="inner-page-section-header text-center">
<h2>GET MEDICAL INSURANCE QUOTE</h2>
<h4 class="mt-4">Declaration</h4>
<p class="purple-text-color">Please note that you must answer all questions, and answer them truthfully.<br>
Failure to do so may result in your policy being cancelled without notice.</p>
</header>
</div>
</section>
<!-- #medical_insurance_intro -->
<!--==========================
Insurance Form Section
============================-->
<section id="medical_insurance_form" class="clearfix">
<div class="container">
<div class="row row-content mb-5">
<div class="col-lg-2 d-none d-lg-block"></div>
<div class="col-xl-8 col-lg-8 col-md-8 main-content declaration-container">
<form action="medical-family-quotes.html" method="post" id="medical_form">
<div class="w-100 mb-4" id="member_1_declaration">
<div class="row mb-4">
<div class="col-12">
<h3 class="mb-0">Member 1</h3>
<p class="purple-text-color">Male</p>
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the cardiovascular system incl. hypertension</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[0].value" id="members[0].answers[0].yes" value="yes" />
<label class="button-label" for="members[0].answers[0].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[0].value" id="members[0].answers[0].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[0].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the respiratory system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[1].value" id="members[0].answers[1].yes" value="yes" />
<label class="button-label" for="members[0].answers[1].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[1].value" id="members[0].answers[1].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[1].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of digestive system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[2].value" id="members[0].answers[2].yes" value="yes" />
<label class="button-label" for="members[0].answers[2].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[2].value" id="members[0].answers[2].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[2].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of genitourinary system, kidney diseases and breast disorders</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[3].value" id="members[0].answers[3].yes" value="yes" />
<label class="button-label" for="members[0].answers[3].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[3].value" id="members[0].answers[3].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[3].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Osteoarticular & Muscular Diseases or Transplants or Disease of the skin and subcutaneous tissue</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[4].value" id="members[0].answers[4].yes" value="yes" />
<label class="button-label" for="members[0].answers[4].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[4].value" id="members[0].answers[4].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[4].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the nervous system and sense organs (ears, eyes, nose)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[5].value" id="members[0].answers[5].yes" value="yes" />
<label class="button-label" for="members[0].answers[5].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[5].value" id="members[0].answers[5].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[5].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the endocrine system, nutritional-, metabolic diseases and immunity disorders, diabetes</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[6].value" id="members[0].answers[6].yes" value="yes" />
<label class="button-label" for="members[0].answers[6].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[6].value" id="members[0].answers[6].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[6].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Neoplasms/Cancer (benign or malignant)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[7].value" id="members[0].answers[7].yes" value="yes" />
<label class="button-label" for="members[0].answers[7].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[7].value" id="members[0].answers[7].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[7].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Sexually Transmitted Diseases & AIDs</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[8].value" id="members[0].answers[8].yes" value="yes" />
<label class="button-label" for="members[0].answers[8].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[8].value" id="members[0].answers[8].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[8].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Congenital anomalies, hereditary/genetic diseases</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[9].value" id="members[0].answers[9].yes" value="yes" />
<label class="button-label" for="members[0].answers[9].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[9].value" id="members[0].answers[9].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[9].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Other Diseases, Accidents, Previous or Future operations you already know about</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[10].value" id="members[0].answers[10].yes" value="yes" />
<label class="button-label" for="members[0].answers[10].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[10].value" id="members[0].answers[10].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[10].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Is the adherent following or has ever followed any medical treatment? Did or is he taking medication?</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[11].value" id="members[0].answers[11].yes" value="yes" />
<label class="button-label" for="members[0].answers[11].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[11].value" id="members[0].answers[11].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[11].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Does the adherent have any allergy against any Drug, Food or other?</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[12].value" id="members[0].answers[12].yes" value="yes" />
<label class="button-label" for="members[0].answers[12].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[12].value" id="members[0].answers[12].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[12].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Pregnant or trying to get pregnant, or any previous complications in pregnancy, childbirth or abortion</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[13].value" id="members[0].answers[13].yes" value="yes" />
<label class="button-label" for="members[0].answers[13].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[13].value" id="members[0].answers[13].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[13].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Infectious and parasitic diseases</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[14].value" id="members[0].answers[14].yes" value="yes" />
<label class="button-label" for="members[0].answers[14].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[14].value" id="members[0].answers[14].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[14].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of blood and blood forming organs</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[15].value" id="members[0].answers[15].yes" value="yes" />
<label class="button-label" for="members[0].answers[15].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[15].value" id="members[0].answers[15].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[15].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Mental-/psychiatric disorders</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[16].value" id="members[0].answers[16].yes" value="yes" />
<label class="button-label" for="members[0].answers[16].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[16].value" id="members[0].answers[16].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[16].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the musculoskeletal system and connective tissue</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[17].value" id="members[0].answers[17].yes" value="yes" />
<label class="button-label" for="members[0].answers[17].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[17].value" id="members[0].answers[17].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[17].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Certain conditions originating in the perinatal period</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[18].value" id="members[0].answers[18].yes" value="yes" />
<label class="button-label" for="members[0].answers[18].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[18].value" id="members[0].answers[18].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[18].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Injury and poisoning</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[19].value" id="members[0].answers[19].yes" value="yes" />
<label class="button-label" for="members[0].answers[19].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[19].value" id="members[0].answers[19].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[19].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Previous medical/surgical hospitalisations, procedures and operations</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[20].value" id="members[0].answers[20].yes" value="yes" />
<label class="button-label" for="members[0].answers[20].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[20].value" id="members[0].answers[20].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[20].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Any (chronic) disease(s), symptoms and complaints not mentioned above</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[21].value" id="members[0].answers[21].yes" value="yes" />
<label class="button-label" for="members[0].answers[21].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[21].value" id="members[0].answers[21].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[21].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Any Pre-existing disease(s), symptoms and complaints within the last ten years</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[0].answers[22].value" id="members[0].answers[22].yes" value="yes" />
<label class="button-label" for="members[0].answers[22].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[0].answers[22].value" id="members[0].answers[22].no" value="no" checked="checked" />
<label class="button-label" for="members[0].answers[22].no">
<p>No</p>
</label>
</div>
</div>
</div>
</div>
<div class="w-100 mb-4" id="member_2_declaration">
<div class="row mb-4">
<div class="col-12">
<h3 class="mb-0">Member 2</h3>
<p class="purple-text-color">Female (Married)</p>
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the cardiovascular system incl. hypertension</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[0].value" id="members[1].answers[0].yes" value="yes" />
<label class="button-label" for="members[1].answers[0].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[0].value" id="members[1].answers[0].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[0].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the respiratory system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[1].value" id="members[1].answers[1].yes" value="yes" />
<label class="button-label" for="members[1].answers[1].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[1].value" id="members[1].answers[1].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[1].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of digestive system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[2].value" id="members[1].answers[2].yes" value="yes" />
<label class="button-label" for="members[1].answers[2].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[2].value" id="members[1].answers[2].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[2].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of genitourinary system, kidney diseases and breast disorders</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[3].value" id="members[1].answers[3].yes" value="yes" />
<label class="button-label" for="members[1].answers[3].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[3].value" id="members[1].answers[3].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[3].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Osteoarticular & Muscular Diseases or Transplants or Disease of the skin and subcutaneous tissue</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[4].value" id="members[1].answers[4].yes" value="yes" />
<label class="button-label" for="members[1].answers[4].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[4].value" id="members[1].answers[4].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[4].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the nervous system and sense organs (ears, eyes, nose)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[5].value" id="members[1].answers[5].yes" value="yes" />
<label class="button-label" for="members[1].answers[5].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[5].value" id="members[1].answers[5].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[5].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the endocrine system, nutritional-, metabolic diseases and immunity disorders, diabetes</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[6].value" id="members[1].answers[6].yes" value="yes" />
<label class="button-label" for="members[1].answers[6].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[6].value" id="members[1].answers[6].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[6].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Neoplasms/Cancer (benign or malignant)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[7].value" id="members[1].answers[7].yes" value="yes" />
<label class="button-label" for="members[1].answers[7].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[7].value" id="members[1].answers[7].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[7].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Sexually Transmitted Diseases & AIDs</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[8].value" id="members[1].answers[8].yes" value="yes" />
<label class="button-label" for="members[1].answers[8].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[8].value" id="members[1].answers[8].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[8].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Congenital anomalies, hereditary/genetic diseases</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[9].value" id="members[1].answers[9].yes" value="yes" />
<label class="button-label" for="members[1].answers[9].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[9].value" id="members[1].answers[9].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[9].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Other Diseases, Accidents, Previous or Future operations you already know about</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[10].value" id="members[1].answers[10].yes" value="yes" />
<label class="button-label" for="members[1].answers[10].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[10].value" id="members[1].answers[10].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[10].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Is the adherent following or has ever followed any medical treatment? Did or is he taking medication?</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[11].value" id="members[1].answers[11].yes" value="yes" />
<label class="button-label" for="members[1].answers[11].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[11].value" id="members[1].answers[11].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[11].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Does the adherent have any allergy against any Drug, Food or other?</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[12].value" id="members[1].answers[12].yes" value="yes" />
<label class="button-label" for="members[1].answers[12].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[12].value" id="members[1].answers[12].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[12].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Pregnant or trying to get pregnant, or any previous complications in pregnancy, childbirth or abortion</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[13].value" id="members[1].answers[13].yes" value="yes" />
<label class="button-label" for="members[1].answers[13].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[13].value" id="members[1].answers[13].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[13].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Infectious and parasitic diseases</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[14].value" id="members[1].answers[14].yes" value="yes" />
<label class="button-label" for="members[1].answers[14].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[14].value" id="members[1].answers[14].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[14].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of blood and blood forming organs</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[15].value" id="members[1].answers[15].yes" value="yes" />
<label class="button-label" for="members[1].answers[15].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[15].value" id="members[1].answers[15].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[15].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Mental-/psychiatric disorders</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[16].value" id="members[1].answers[16].yes" value="yes" />
<label class="button-label" for="members[1].answers[16].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[16].value" id="members[1].answers[16].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[16].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the musculoskeletal system and connective tissue</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[17].value" id="members[1].answers[17].yes" value="yes" />
<label class="button-label" for="members[1].answers[17].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[17].value" id="members[1].answers[17].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[17].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Certain conditions originating in the perinatal period</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[18].value" id="members[1].answers[18].yes" value="yes" />
<label class="button-label" for="members[1].answers[18].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[18].value" id="members[1].answers[18].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[18].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Injury and poisoning</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[19].value" id="members[1].answers[19].yes" value="yes" />
<label class="button-label" for="members[1].answers[19].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[19].value" id="members[1].answers[19].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[19].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Previous medical/surgical hospitalisations, procedures and operations</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[20].value" id="members[1].answers[20].yes" value="yes" />
<label class="button-label" for="members[1].answers[20].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[20].value" id="members[1].answers[20].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[20].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Any (chronic) disease(s), symptoms and complaints not mentioned above</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[21].value" id="members[1].answers[21].yes" value="yes" />
<label class="button-label" for="members[1].answers[21].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[21].value" id="members[1].answers[21].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[21].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Any Pre-existing disease(s), symptoms and complaints within the last ten years</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[1].answers[22].value" id="members[1].answers[22].yes" value="yes" />
<label class="button-label" for="members[1].answers[22].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[1].answers[22].value" id="members[1].answers[22].no" value="no" checked="checked" />
<label class="button-label" for="members[1].answers[22].no">
<p>No</p>
</label>
</div>
</div>
</div>
</div>
<div class="w-100 mb-4" id="member_3_declaration">
<div class="row mb-4">
<div class="col-12">
<h3 class="mb-0">Member 3</h3>
<p class="purple-text-color">Female (Single)</p>
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the cardiovascular system incl. hypertension</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[0].value" id="members[2].answers[0].yes" value="yes" />
<label class="button-label" for="members[2].answers[0].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[0].value" id="members[2].answers[0].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[0].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the respiratory system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[1].value" id="members[2].answers[1].yes" value="yes" />
<label class="button-label" for="members[2].answers[1].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[1].value" id="members[2].answers[1].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[1].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of digestive system</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[2].value" id="members[2].answers[2].yes" value="yes" />
<label class="button-label" for="members[2].answers[2].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[2].value" id="members[2].answers[2].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[2].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of genitourinary system, kidney diseases and breast disorders</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[3].value" id="members[2].answers[3].yes" value="yes" />
<label class="button-label" for="members[2].answers[3].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[3].value" id="members[2].answers[3].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[3].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Osteoarticular & Muscular Diseases or Transplants or Disease of the skin and subcutaneous tissue</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[4].value" id="members[2].answers[4].yes" value="yes" />
<label class="button-label" for="members[2].answers[4].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[4].value" id="members[2].answers[4].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[4].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the nervous system and sense organs (ears, eyes, nose)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[5].value" id="members[2].answers[5].yes" value="yes" />
<label class="button-label" for="members[2].answers[5].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[5].value" id="members[2].answers[5].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[5].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Diseases of the endocrine system, nutritional-, metabolic diseases and immunity disorders, diabetes</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[6].value" id="members[2].answers[6].yes" value="yes" />
<label class="button-label" for="members[2].answers[6].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[6].value" id="members[2].answers[6].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[6].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Neoplasms/Cancer (benign or malignant)</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[7].value" id="members[2].answers[7].yes" value="yes" />
<label class="button-label" for="members[2].answers[7].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[7].value" id="members[2].answers[7].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[7].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Sexually Transmitted Diseases & AIDs</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[8].value" id="members[2].answers[8].yes" value="yes" />
<label class="button-label" for="members[2].answers[8].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[8].value" id="members[2].answers[8].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[8].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Congenital anomalies, hereditary/genetic diseases</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[9].value" id="members[2].answers[9].yes" value="yes" />
<label class="button-label" for="members[2].answers[9].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[9].value" id="members[2].answers[9].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[9].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Other Diseases, Accidents, Previous or Future operations you already know about</div>
<div class="col-4">
<div class="button-wrap">
<input class="hidden radio-label" type="radio" name="members[2].answers[10].value" id="members[2].answers[10].yes" value="yes" />
<label class="button-label" for="members[2].answers[10].yes">
<p>Yes</p>
</label>
<input class="hidden radio-label" type="radio" name="members[2].answers[10].value" id="members[2].answers[10].no" value="no" checked="checked" />
<label class="button-label" for="members[2].answers[10].no">
<p>No</p>
</label>
</div>
</div>
</div>
<div class="row pt-3 pb-3 declaration-row align-items-center">
<div class="col-8">Is the adherent following or has ever followed any medical treatment? Did or is he taking medication?</div>