{"id":322,"date":"2023-03-22T06:17:40","date_gmt":"2023-03-22T05:17:40","guid":{"rendered":"http:\/\/psypraxis.org\/medical-history-form\/"},"modified":"2023-05-30T08:19:53","modified_gmt":"2023-05-30T06:19:53","slug":"medical-history-form","status":"publish","type":"page","link":"https:\/\/psypraxis.org\/en\/medical-history-form\/","title":{"rendered":"Medical history form"},"content":{"rendered":"<section class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<h1 style=\"text-align: center;\">Medical history form<\/h1>\n<p>[\/vc_column_text][vc_column_text]<\/p>\n<p style=\"text-align: center;\">I am text block. Click edit button to change this text. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.<\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Anamnesebogen Teil2<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/322' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_69\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Beziehungsstatus<\/h3><\/div><fieldset id=\"field_1_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >aktueller Beziehungsstand<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_7'>\n\t\t\t<div class='gchoice gchoice_1_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Alleinstehend'  id='choice_1_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_0' id='label_1_7_0' class='gform-field-label gform-field-label--type-inline'>Alleinstehend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Partnerschaft'  id='choice_1_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_1' id='label_1_7_1' class='gform-field-label gform-field-label--type-inline'>Partnerschaft<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Geschieden'  id='choice_1_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_2' id='label_1_7_2' class='gform-field-label gform-field-label--type-inline'>Geschieden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Verwitwet'  id='choice_1_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_3' id='label_1_7_3' class='gform-field-label gform-field-label--type-inline'>Verwitwet<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Form der Partnerschaft<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_68'>\n\t\t\t<div class='gchoice gchoice_1_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Verheiratet'  id='choice_1_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Verheiratet<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Lebenspartnerschaft'  id='choice_1_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Lebenspartnerschaft<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Seit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Anzahl der Ehen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Kinder<\/h3><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Haben Sie Kinder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_13'>\n\t\t\t<div class='gchoice gchoice_1_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Ja'  id='choice_1_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Nein'  id='choice_1_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Anzahl Kinder<\/label><div class='ginput_container ginput_container_number'><input name='input_45' id='input_1_45' type='number' step='any' min='1'  value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_45\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_45'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_47'>\n\t\t\t<div class='gchoice gchoice_1_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Weiblich'  id='choice_1_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='M\u00e4nnlich'  id='choice_1_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Divers'  id='choice_1_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_49'>\n\t\t\t<div class='gchoice gchoice_1_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Weiblich'  id='choice_1_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='M\u00e4nnlich'  id='choice_1_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Divers'  id='choice_1_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_49_2' id='label_1_49_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_53'>\n\t\t\t<div class='gchoice gchoice_1_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Weiblich'  id='choice_1_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='M\u00e4nnlich'  id='choice_1_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Divers'  id='choice_1_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_2' id='label_1_53_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_51'>\n\t\t\t<div class='gchoice gchoice_1_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Weiblich'  id='choice_1_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_51_0' id='label_1_51_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='M\u00e4nnlich'  id='choice_1_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Divers'  id='choice_1_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_51_2' id='label_1_51_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_59'>\n\t\t\t<div class='gchoice gchoice_1_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Weiblich'  id='choice_1_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_59_0' id='label_1_59_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='M\u00e4nnlich'  id='choice_1_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_59_1' id='label_1_59_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_59_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Divers'  id='choice_1_59_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_59_2' id='label_1_59_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_57'>\n\t\t\t<div class='gchoice gchoice_1_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Weiblich'  id='choice_1_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='M\u00e4nnlich'  id='choice_1_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Divers'  id='choice_1_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_2' id='label_1_57_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_55'>\n\t\t\t<div class='gchoice gchoice_1_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Weiblich'  id='choice_1_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='M\u00e4nnlich'  id='choice_1_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Divers'  id='choice_1_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_2' id='label_1_55_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_61'>\n\t\t\t<div class='gchoice gchoice_1_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Weiblich'  id='choice_1_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_0' id='label_1_61_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='M\u00e4nnlich'  id='choice_1_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Divers'  id='choice_1_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_2' id='label_1_61_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_62\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Weiblich'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='M\u00e4nnlich'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Divers'  id='choice_1_63_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_2' id='label_1_63_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschlecht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_65'>\n\t\t\t<div class='gchoice gchoice_1_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Weiblich'  id='choice_1_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_65_0' id='label_1_65_0' class='gform-field-label gform-field-label--type-inline'>Weiblich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='M\u00e4nnlich'  id='choice_1_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>M\u00e4nnlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Divers'  id='choice_1_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_65_2' id='label_1_65_2' class='gform-field-label gform-field-label--type-inline'>Divers<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Familienmitglieder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Enkel'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Enkel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Abtreibungen'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>Abtreibungen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Fehlgeburten'  id='choice_1_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2' class='gform-field-label gform-field-label--type-inline'>Fehlgeburten<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Totgeburten'  id='choice_1_22_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_3' id='label_1_22_3' class='gform-field-label gform-field-label--type-inline'>Totgeburten<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Engste Bezugsperson<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Wo aufgewachsen (Ort \/ Land)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-two-thirds gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Aufgewachsen bei<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Eltern'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Eltern<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Elternteil (Mutter\/Vater)'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>Elternteil (Mutter\/Vater)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Gro\u00dfeltern'  id='choice_1_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_2' id='label_1_33_2' class='gform-field-label gform-field-label--type-inline'>Gro\u00dfeltern<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Pflegeeltern'  id='choice_1_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_3' id='label_1_33_3' class='gform-field-label gform-field-label--type-inline'>Pflegeeltern<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Heim'  id='choice_1_33_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_4' id='label_1_33_4' class='gform-field-label gform-field-label--type-inline'>Heim<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geschwister<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_34'>\n\t\t\t<div class='gchoice gchoice_1_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Ja'  id='choice_1_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Nein'  id='choice_1_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Arbeitssituation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_43'>\n\t\t\t<div class='gchoice gchoice_1_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Erwerbst\u00e4tig'  id='choice_1_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>Erwerbst\u00e4tig<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Arbeitssuchend'  id='choice_1_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Arbeitssuchend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Pension'  id='choice_1_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Nicht erwerbst\u00e4tig'  id='choice_1_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_3' id='label_1_43_3' class='gform-field-label gform-field-label--type-inline'>Nicht erwerbst\u00e4tig<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Erwerbst\u00e4tig<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_71'>\n\t\t\t<div class='gchoice gchoice_1_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Vollzeit'  id='choice_1_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Vollzeit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Teilzeit'  id='choice_1_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>Teilzeit<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_72\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_72'>Berufsbezeichnung<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Arbeitssuchend<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_73'>\n\t\t\t<div class='gchoice gchoice_1_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Arbeitslosengeld'  id='choice_1_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_73_0' id='label_1_73_0' class='gform-field-label gform-field-label--type-inline'>Arbeitslosengeld<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Notstandshilfe'  id='choice_1_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_73_1' id='label_1_73_1' class='gform-field-label gform-field-label--type-inline'>Notstandshilfe<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Pension<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_74'>\n\t\t\t<div class='gchoice gchoice_1_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Invalidit\u00e4tspension'  id='choice_1_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_74_0' id='label_1_74_0' class='gform-field-label gform-field-label--type-inline'>Invalidit\u00e4tspension<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Alterspension'  id='choice_1_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_74_1' id='label_1_74_1' class='gform-field-label gform-field-label--type-inline'>Alterspension<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Seit (MM\/JJJJ)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Essst\u00f6rungen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Ja'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Nein'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Fr\u00fcher'  id='choice_1_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2' class='gform-field-label gform-field-label--type-inline'>Fr\u00fcher<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Wann waren die Essst\u00f6rungen<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Selbstverletzung<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_40'>\n\t\t\t<div class='gchoice gchoice_1_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Ja'  id='choice_1_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_0' id='label_1_40_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Nein'  id='choice_1_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_1' id='label_1_40_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_41\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Wie oft<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Wann<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >h\u00f6chste abgeschlossene Ausbildung<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_75'>\n\t\t\t<div class='gchoice gchoice_1_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Pflichtschule'  id='choice_1_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_0' id='label_1_75_0' class='gform-field-label gform-field-label--type-inline'>Pflichtschule<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Matura (Abitur, Meisterpr\u00fcfung, etc.)'  id='choice_1_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_1' id='label_1_75_1' class='gform-field-label gform-field-label--type-inline'>Matura (Abitur, Meisterpr\u00fcfung, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Akademischer Abschluss (BA, MS, PhD)'  id='choice_1_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_2' id='label_1_75_2' class='gform-field-label gform-field-label--type-inline'>Akademischer Abschluss (BA, MS, PhD)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Ihre Hobbys<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wohnsituation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Mietwohnung'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Mietwohnung<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Eigentum (Wohnung\/Haus)'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Eigentum (Wohnung\/Haus)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='WG'  id='choice_1_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>WG<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Wohnkosten pro Monat<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Schulden<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_30'>\n\t\t\t<div class='gchoice gchoice_1_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Ja'  id='choice_1_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Nein'  id='choice_1_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_31\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>Seit wann (MM\/JJJJ)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Wie hoch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie h\u00e4ufig haben Sie sexuellen Kontakt<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_8'>\n<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_8'>\n\t\t\t<div class='gchoice gchoice_1_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Nie'  id='choice_1_8_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_8\"   \/>\n\t\t\t\t\t<label for='choice_1_8_0' id='label_1_8_0' class='gform-field-label gform-field-label--type-inline'>Nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='&lt;1x \/Monat'  id='choice_1_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_1' id='label_1_8_1' class='gform-field-label gform-field-label--type-inline'>&lt;1x \/Monat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='1-4x \/ Monat'  id='choice_1_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_2' id='label_1_8_2' class='gform-field-label gform-field-label--type-inline'>1-4x \/ Monat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='5-10x \/ Monate'  id='choice_1_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_3' id='label_1_8_3' class='gform-field-label gform-field-label--type-inline'>5-10x \/ Monate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='10+ \/Monaat'  id='choice_1_8_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_4' id='label_1_8_4' class='gform-field-label gform-field-label--type-inline'>10+ \/Monaat<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Zufriedenheit mit sexuellen Kotakt(en)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_9'>Schulnote 1 (sehr zufrieden) -5 (sehr unzufrieden)<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='1'  id='choice_1_9_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_9\"   \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='2'  id='choice_1_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='3'  id='choice_1_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='4'  id='choice_1_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_3' id='label_1_9_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='5'  id='choice_1_9_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_4' id='label_1_9_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='6'  id='choice_1_9_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_9_5' id='label_1_9_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Schlaf<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_20'>Schulnote 1-5 bzw. 6 = kein Sex seit \u00fcber einem Jahr<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_20'>\n\t\t\t<div class='gchoice gchoice_1_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='1'  id='choice_1_20_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_20\"   \/>\n\t\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='2'  id='choice_1_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='3'  id='choice_1_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='4'  id='choice_1_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='5'  id='choice_1_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='6'  id='choice_1_20_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sucht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_36'>\n\t\t\t<div class='gchoice gchoice_1_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Ja'  id='choice_1_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Nein'  id='choice_1_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Abstinent'  id='choice_1_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Abstinent<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Welche Sucht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Spielsucht'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>Spielsucht<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Alkohol'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>Alkohol<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Nikotin'  id='choice_1_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_2' id='label_1_37_2' class='gform-field-label gform-field-label--type-inline'>Nikotin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Medikamente'  id='choice_1_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_3' id='label_1_37_3' class='gform-field-label gform-field-label--type-inline'>Medikamente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Drogen'  id='choice_1_37_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_4' id='label_1_37_4' class='gform-field-label gform-field-label--type-inline'>Drogen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='sonstiges'  id='choice_1_37_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_5' id='label_1_37_5' class='gform-field-label gform-field-label--type-inline'>sonstiges<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Traumatisierte\/erlebte Gewalt<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_27'>\n\t\t\t<div class='gchoice gchoice_1_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Nein'  id='choice_1_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_0' id='label_1_27_0' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Ja'  id='choice_1_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Beschreiben Sie Ihre Traumatisierung<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>K\u00f6rperliche Diagnosen \/ Operationen:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Nehmen Sie aktuell Medikamente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_76'>\n\t\t\t<div class='gchoice gchoice_1_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Ja'  id='choice_1_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_0' id='label_1_76_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Nein'  id='choice_1_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_76_1' id='label_1_76_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Aktuelle Medikation:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sind Sie aktuell in psychosozialer Betreuung<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_77'>\n\t\t\t<div class='gchoice gchoice_1_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Ja'  id='choice_1_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_77_0' id='label_1_77_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Nein'  id='choice_1_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_77_1' id='label_1_77_1' class='gform-field-label gform-field-label--type-inline'>Nein<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Psychosoziale Betreuung:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Aktuelle psychische Probleme \/ Diagnosen::<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Aktuelle psy. Behandlung bei:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Psy. 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