{"id":1188,"date":"2019-01-18T15:18:31","date_gmt":"2019-01-18T15:18:31","guid":{"rendered":"https:\/\/kidneyresearchuk.org\/?page_id=1188"},"modified":"2025-10-22T09:12:34","modified_gmt":"2025-10-22T08:12:34","slug":"kidneyhealthcheck","status":"publish","type":"page","link":"https:\/\/www.kidneyresearchuk.org\/kidney-health-information\/kidneyhealthcheck\/","title":{"rendered":"Kidney health check"},"content":{"rendered":"\n\n    <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework healthcheck_quiz_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_57' style='display:none'><div id='gf_57' class='gform_anchor' tabindex='-1'><\/div>\t<script>\n\tif(window.jQuery){\n\t\tconsole.log('load gform_form_tag script');\n\t\tvar current_lookup_form = '';\n\t\tvar current_lookup_field = '';\n\t\tjQuery(document).ready(function($) {\n\t\t$('body').on('click', '.pcaitem', function() {\n\t\t\t\tconsole.log('form tag - pca item clicked');\t\t\t\n\t\t\t\t$('#field_'+current_lookup_form+'_'+current_lookup_field+' span').show();\n\t\t\t\t$('#enter_address_manually_'+current_lookup_field).hide();\n\t\t\t\t$('#input_'+current_lookup_form+'_'+current_lookup_field+'_1_container').find('label').text('Address Line 1');\n\t\t\t});\n\t\t});\n\t}else{\n\t\tconsole.log('jQuery check (loqate_scripts_css)');\n\t}\n\t<\/script><!-- LOQATE --><link rel=\"stylesheet\" type=\"text\/css\" href=\"https:\/\/services.postcodeanywhere.co.uk\/css\/address-3.91.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/services.postcodeanywhere.co.uk\/js\/address-3.91.js\"><\/script><!-- LOQATE --> <form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_57' id='gform_57' class='healthcheck_quiz' action='\/wp-json\/wp\/v2\/pages\/1188#gf_57' data-formid='57' novalidate>\n        <div id='gf_progressbar_wrapper_57' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>11<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_9' style='width:9%; color:#333333; background-color:#0ab587;'><span>9%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_57_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_57' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_57_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><div class='ginput_container ginput_container_text'><input name='input_51' id='input_57_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='26\/12\/2025' \/><\/div><!-- end --><\/div><div id=\"field_57_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><div class=\"intro-text\"><h2>Are my kidneys healthy?<\/h2><p>Every day 23 people start treatment for kidney failure.<\/p><p>\nPeople can have kidney problems without being aware of it.<\/p><p><strong>Take our quick and easy health check, to see if you are at risk of kidney disease.<\/strong><\/p><\/div><!-- end --><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_57_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_2' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full radio-btn large_label field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label' >Do you have diabetes?<\/legend><div class='gfield_description' id='gfield_description_57_11'>Diabetes is the most common disease affecting the kidneys that results in patients needing dialysis.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_57_11'>\n\t\t\t<div class='gchoice gchoice_57_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Diabetes: up to 40% of people with diabetes will develop kidney disease, so regular monitoring, at least annually, is recommended.'  id='choice_57_11_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_57_11\"   \/>\n\t\t\t\t\t<label for='choice_57_11_0' id='label_57_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Low risk'  id='choice_57_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_11_1' id='label_57_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_12' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_12' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_3' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full multichoice-radio large_label field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label' >Do you have, or are you being treated for, high blood pressure?<\/legend><div class='gfield_description' id='gfield_description_57_13'>High blood pressure puts strain on your blood vessels and certain organs, including the kidneys.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_57_13'>\n\t\t\t<div class='gchoice gchoice_57_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='High blood pressure: this can lead to kidney damage or, in some cases, be a sign of kidney disease.'  id='choice_57_13_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_57_13\"   \/>\n\t\t\t\t\t<label for='choice_57_13_0' id='label_57_13_0' class='gform-field-label gform-field-label--type-inline'>Yes, I have high blood pressure but I'm not being treated<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='High blood pressure: this can lead to kidney damage or, in some cases, be a sign of kidney disease.'  id='choice_57_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_13_1' id='label_57_13_1' class='gform-field-label gform-field-label--type-inline'>Yes, I am being treated for high blood pressure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Low risk'  id='choice_57_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_13_2' id='label_57_13_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_16' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_16' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_4' class='gform_page' data-js='page-field-id-16' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full multichoice-radio large_label field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you had any of the following circulation problems?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_57'><div class='gchoice gchoice_57_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Angina: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_1' id='label_57_57_1' class='gform-field-label gform-field-label--type-inline'>Angina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Heart attack: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_2' id='label_57_57_2' class='gform-field-label gform-field-label--type-inline'>Heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Stroke: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_3' id='label_57_57_3' class='gform-field-label gform-field-label--type-inline'>Stroke or mini stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Poor circulation: pain in the leg muscles after walking a short distance may indicate circulation problems that could be associated with kidney disease'  id='choice_57_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_4' id='label_57_57_4' class='gform-field-label gform-field-label--type-inline'>Poor circulation in your legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Poor circulation: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_5' id='label_57_57_5' class='gform-field-label gform-field-label--type-inline'>Amputation due to poor circulation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Aortic aneurysm: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_6' id='label_57_57_6' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Heart failure: this may be associated with narrowing of the arteries that supply the kidneys, which can cause kidney damage'  id='choice_57_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_7' id='label_57_57_7' class='gform-field-label gform-field-label--type-inline'>Heart failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='Low risk'  id='choice_57_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_57_8' id='label_57_57_8' class='gform-field-label gform-field-label--type-inline'>None of these<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_5' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full multichoice-radio large_label field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you had any of the following?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_58'><div class='gchoice gchoice_57_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Multiple kidney stones: this can cause scarring of the kidneys and can result in reduced kidney function'  id='choice_57_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_1' id='label_57_58_1' class='gform-field-label gform-field-label--type-inline'>Multiple kidney stones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Multiple urine infections: this can cause scarring of the kidneys, especially if they occur in children, and can result in reduced kidney function'  id='choice_57_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_2' id='label_57_58_2' class='gform-field-label gform-field-label--type-inline'>Multiple urine infections, for example three or more in a six month period<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='Kidney surgery: this can cause scarring of the kidneys and can result in reduced kidney function'  id='choice_57_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_3' id='label_57_58_3' class='gform-field-label gform-field-label--type-inline'>Kidney surgery - such as having a kidney removed or a \"stent\" to either or both kidneys<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.4' type='checkbox'  value='Enlarged prostate gland: this can cause difficulty in passing urine of having to strain during passing urine. Both can cause scarring of the kidneys and can result in reduced kidney function'  id='choice_57_58_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_4' id='label_57_58_4' class='gform-field-label gform-field-label--type-inline'>Enlarged prostate gland  - sometimes called \"BPH\"<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.5' type='checkbox'  value='Bladder, prostate or kidney cancer: this can cause scarring of the kidneys and can result in reduced kidney function'  id='choice_57_58_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_5' id='label_57_58_5' class='gform-field-label gform-field-label--type-inline'>Bladder, prostate or kidney cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.6' type='checkbox'  value='Acute kidney injury can cause partial or complete loss of kidney function which can be temporary or longer lasting'  id='choice_57_58_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_6' id='label_57_58_6' class='gform-field-label gform-field-label--type-inline'>Previous episode of acute kidney injury (AKI) - temporary drop in kidney function<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_58_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.7' type='checkbox'  value='Low risk'  id='choice_57_58_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_58_7' id='label_57_58_7' class='gform-field-label gform-field-label--type-inline'>None of these<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_31' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_31' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_6' class='gform_page' data-js='page-field-id-31' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_6' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full multichoice-radio large_label field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you been diagnosed with any of the following<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_59'><div class='gchoice gchoice_57_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Systemic Lupus erythematosus: this can have a damaging effect on different organs in the body including the kidneys.'  id='choice_57_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_1' id='label_57_59_1' class='gform-field-label gform-field-label--type-inline'>Lupus (systemic lupus erythematosus or SLE)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Myeloma: this can have a damaging effect on different organs in the body including your kidneys'  id='choice_57_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_2' id='label_57_59_2' class='gform-field-label gform-field-label--type-inline'>Myeloma or if you are known to have a \"paraprotein\" in your blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Rheumatoid arthritis: this can have a damaging effect on different organs in the body including your kidneys'  id='choice_57_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_3' id='label_57_59_3' class='gform-field-label gform-field-label--type-inline'>Rheumatoid arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Liver disease: this can have a damaging effect on different organs in the body including your kidneys'  id='choice_57_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_4' id='label_57_59_4' class='gform-field-label gform-field-label--type-inline'>Liver disease (including cirrhosis)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Sickle cell disease: this can have a damaging effect on different organs in the body including your kidneys'  id='choice_57_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_5' id='label_57_59_5' class='gform-field-label gform-field-label--type-inline'>Sickle cell disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.6' type='checkbox'  value='HIV: this can have a damaging effect on different organs in the body including your kidneys'  id='choice_57_59_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_6' id='label_57_59_6' class='gform-field-label gform-field-label--type-inline'>HIV infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_59_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.7' type='checkbox'  value='Low risk'  id='choice_57_59_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_59_7' id='label_57_59_7' class='gform-field-label gform-field-label--type-inline'>None of these<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_32' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_32' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_7' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_7' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full multichoice-radio large_label field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a family history of kidney disease?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_60'><div class='gchoice gchoice_57_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Family history: some kidney diseases are caused by abnormalities in genes that may be passed from one generation to the next'  id='choice_57_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_60_1' id='label_57_60_1' class='gform-field-label gform-field-label--type-inline'>Parent or child who has a kidney disease that may be inherited<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Family history: some kidney diseases are caused by abnormalities in genes that may be passed from one generation to the next'  id='choice_57_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_60_2' id='label_57_60_2' class='gform-field-label gform-field-label--type-inline'>Parent or child who requires regular kidney dialysis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Family history: some kidney diseases are caused by abnormalities in genes that may be passed from one generation to the next'  id='choice_57_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_60_3' id='label_57_60_3' class='gform-field-label gform-field-label--type-inline'>Parent or child who has had a kidney transplant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='Low risk'  id='choice_57_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_60_4' id='label_57_60_4' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_8' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_8' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full radio-btn large_label field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label' >Have you ever had a urine test that was positive for blood or protein?<\/legend><div class='gfield_description' id='gfield_description_57_38'>The presence of protein in the urine can sometimes be a sign of kidney disease, as well as other health problems.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_57_38'>\n\t\t\t<div class='gchoice gchoice_57_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Abnormal urine test: in some, but not all, cases this can be a sign of kidney disease so it&#039;s worth further investigation'  id='choice_57_38_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_57_38\"   \/>\n\t\t\t\t\t<label for='choice_57_38_0' id='label_57_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Low risk'  id='choice_57_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_38_1' id='label_57_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_37' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_37' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_9' class='gform_page' data-js='page-field-id-37' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_9' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full multichoice-radio large_label field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you taking any of the following drugs?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_61'><div class='gchoice gchoice_57_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Any non-steroidal anti-inflammatory drugs: these drugs may cause kidney function to decrease slowly. They should not be taken over a long period, but if it&#039;s essential you should ask for a kidney function check at least annually'  id='choice_57_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_1' id='label_57_61_1' class='gform-field-label gform-field-label--type-inline'>Any non-steroidal anti-inflammatory drugs (e.g. ibuprofen or naproxen)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Ciclosporin: this drug may cause kidney function to decrease slowly. If you&#039;re taking it over a long period you should ask for a kidney function check at least annually'  id='choice_57_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_2' id='label_57_61_2' class='gform-field-label gform-field-label--type-inline'>Ciclosporin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Tacrolimus: this drug may cause kidney function to decrease slowly. If you&#039;re taking it over a long period you should ask for a kidney function check at least annually'  id='choice_57_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_3' id='label_57_61_3' class='gform-field-label gform-field-label--type-inline'>Tacrolimus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Lithium: this drug may cause kidney function to decrease slowly. If you&#039;re taking it over a long period you should ask for a kidney function check at least annually'  id='choice_57_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_4' id='label_57_61_4' class='gform-field-label gform-field-label--type-inline'>Lithium<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Mesalazine: this drug may cause kidney function to decrease slowly. If you&#039;re taking it over a long period you should ask for a kidney function check at least annually'  id='choice_57_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_5' id='label_57_61_5' class='gform-field-label gform-field-label--type-inline'>Mesalazine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_57_61_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.6' type='checkbox'  value='Low risk'  id='choice_57_61_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_61_6' id='label_57_61_6' class='gform-field-label gform-field-label--type-inline'>None of these<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_52' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_52' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_10' class='gform_page booklet' data-js='page-field-id-52' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_10' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_57_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full radio-btn large_label kidney-booklet field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label' >Would you like a FREE Get kidney fit booklet?<\/legend><div class='gfield_description' id='gfield_description_57_24'><p>Help us to go green by downloading the Get kidney fit booklet in digital format. Get kidney fit booklet is a handy guide to your kidneys and how to look after them.<\/p><\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_57_24'>\n\t\t\t<div class='gchoice gchoice_57_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_57_24_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_57_24\"   \/>\n\t\t\t\t\t<label for='choice_57_24_0' id='label_57_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_57_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_24_1' id='label_57_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><fieldset id=\"field_57_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full booklet-print field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Printed booklet request<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_44'><div class='gchoice gchoice_57_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Yes'  id='choice_57_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_44_1' id='label_57_44_1' class='gform-field-label gform-field-label--type-inline'>Please let us know if you would prefer\u00a0a printed booklet.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_57_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_57_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_57_11' class='gform_page results' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_57_11' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_57_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><h3 class=\"gsection_title\">Great, nearly done...<\/h3><!-- end --><\/div><fieldset id=\"field_57_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full radio-btn large_label healthcheck_email-results gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label' >Would you like to get an email of your results?<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_57_5'>\n\t\t\t<div class='gchoice gchoice_57_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_57_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_5_0' id='label_57_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_57_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_57_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_57_5_1' id='label_57_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><div id=\"field_57_41\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full email-results field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><!-- start --><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_57_41'>Emailed Health Check Results<\/label><div class='gfield_description' id='gfield_description_57_41'>Field value will be embedded in the user notification email.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_57_41' class='textarea large'  aria-describedby=\"gfield_description_57_41\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><!-- end --><\/div><div id=\"field_57_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><h3 class=\"gsection_title\"><\/h3><!-- end --><\/div><div id=\"field_57_18\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><div class=\"blue_line-bullets\">\n<div id=\"low-risk\">\n<p>Based on your responses today you are at low risk of kidney disease and don\u2019t require any further tests.<\/p>\n<p>Consider the following advice to help keep your kidneys healthy in the future:<\/p>\n<ul><li>Avoid a high salt diet and don\u2019t add salt to your food at the table<\/li><li>Stick to a healthy diet<\/li><li>Maintain a healthy weight<\/li><li>Keep active and exercise regularly<\/li><li>Don\u2019t smoke<\/li><li>Avoid regular or long-term use of pain medication, unless prescribed by your doctor<\/li><\/ul>\n<\/div>\n\n<div id=\"pre-results\">\n<p>Based on your responses today if you have not had your kidney function checked before, you should make an appointment with your GP for a simple blood and urine test.<\/p>\n<p>Your assessment highlighted the following as possible risk factors:<\/p>\n<\/div>\n<div id=\"screen-results\"><\/div>\n<\/div><!-- end --><\/div><div id=\"field_57_54\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><h3>Where should we send your results?<\/h3><!-- end --><\/div><div id=\"field_57_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><h3>Where should we send your booklet?<\/h3><!-- end --><\/div><fieldset id=\"field_57_19\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full copy-19.3-to-25.3 copy-19.6-to-25.6 gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_57_19'>\n                            \n                            <span id='input_57_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_57_19_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                    <input type='text' name='input_19.3' id='input_57_19_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_57_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_57_19_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                            <input type='text' name='input_19.6' id='input_57_19_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><!-- end --><\/fieldset><div id=\"field_57_20\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full copy-20-to-43 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><label class='gfield_label gform-field-label' for='input_57_20'>Your email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_57_20' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><!-- end --><\/div><div id=\"field_57_55\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><h3>Where should we send your booklet?<\/h3><!-- end --><\/div><fieldset id=\"field_57_26\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full pink-section bl_gf_address-search gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_57_26' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_57_26_1_container' >\n                                        <label for='input_57_26_1' id='input_57_26_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                        <input type='text' name='input_26.1' id='input_57_26_1'  maxlength='' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_57_26_2_container' >\n                                        <label for='input_57_26_2' id='input_57_26_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_26.2' id='input_57_26_2'  maxlength='' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_57_26_3_container' >\n                                    <label for='input_57_26_3' id='input_57_26_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_26.3' id='input_57_26_3'  maxlength='' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_57_26_4_container' >\n                                        <label for='input_57_26_4' id='input_57_26_4_label' class='gform-field-label gform-field-label--type-sub '>County<\/label>\n                                        <input type='text' name='input_26.4' id='input_57_26_4'  maxlength='' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_57_26_5_container' >\n                                    <label for='input_57_26_5' id='input_57_26_5_label' class='gform-field-label gform-field-label--type-sub '>Postcode<\/label>\n                                    <input type='text' name='input_26.5' id='input_57_26_5'  maxlength='' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_57_26_6_container' >\n                                        <label for='input_57_26_6' id='input_57_26_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_26.6' id='input_57_26_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' selected='selected'>United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><!-- end --><!--address [pink-section bl_gf_address-search] [26]--><script>\nif (window.jQuery) {\n\t\/\/-- map form fields to address sections --\/\/\n\tvar fields = [\n\t\t{element:\"input_26.1\",field:\"Line1\"},\n\t\t{element:\"input_26.2\",field:\"Line2\",mode: pca.fieldMode.POPULATE},\n\t\t{element:\"input_26.3\",field:\"City\",mode: pca.fieldMode.POPULATE},\n\t\t{element:\"input_26.4\",field:\"Province\",mode: pca.fieldMode.POPULATE},\n\t\t{element:\"input_26.5\",field:\"PostalCode\"},\n\t\t{element:\"input_26.6\",field:\"CountryName\",mode: pca.fieldMode.POPULATE|pca.fieldMode.COUNTRY},  \n\t];\n\n\toptions = {\n\t\tkey: \"UX99-MR49-KG88-RT55\"\n\t};\n\n\tvar control_26 = new pca.Address(fields,options);\n\t\n\tvar current_lookup_field = '';\n\t\n\tvar lookup = 0;\n\tjQuery(document).ready(function($) {\n\t\t\/\/get containing fieldset\n\t\tfieldset = $('#field_57_26');\n\t\tconsole.log('Address fieldset:');\n\t\tconsole.log(fieldset);\n\t\t\n\t\t\n\t\t\/\/does it have an error?\n\t\terror = fieldset.hasClass('gfield_error');\n\t\t\n\t\tif(fieldset.hasClass('gfield_error')){\n\t\t\t\/\/console.log('do not collapse fields');\n\t\t}\n\t\n\t\taddress_line_1 = $('#input_57_26_1_container'); \/\/ get the containing span\n\t\taddress_line_1_input = $('#input_57_26_1');\n\t\t\/\/console.log(address_line_1);\n\t\t\/\/console.log(address_line_1_input);\n\t\t\n\t\tif(!error){\n\t\t\tfieldset.addClass('bl_gf_address-search');\n\t\t\taddress_line_1_input.after(\"<a id='enter_address_manually_26' class='manual_address_btn'>Enter Address Manually<\/a><!-- added by bl_gf_extension -->\");\n\t\t\n\t\t\t\/\/console.log('#field_57_26');\n\t\t\t$('#field_57_26 .ginput_container span').hide();\n\t\t\taddress_line_1.show();\n        \taddress_line_1.find('input').attr('placeholder', 'Start typing postcode or address');\n       \t\taddress_line_1.find('label').text('Address Lookup');\n       \t\t\/\/address_line_1.find('label').hide();\n        }\n        \n        \/\/attach button handler\n        $('#enter_address_manually_26').click(function(e) {\n        \tconsole.log('setting expanded class - 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autocomplete visible ');\n\t\t\t\t\t$('#field_57_26 span').show();\n\t\t\t\t\t$('#enter_address_manually_26').hide();\n\t\t\t\t\taddress_line_1 = $('#input_57_26_1_container');\n\t\t\t\t\taddress_line_1.find('label').text('Address Line 1');\n\t\t\t\t\taddress_line_1.find('label').show();\n\t\t\t\t\tfieldset.removeClass('bl_gf_address-search');\n        \t\t\tfieldset.addClass('bl_gf_address-expanded');\n\t\t\t\t}\n\t\t\t}\n\t\t});\n\t\t\n\t\t$('#input_57_26_1').focusout(function(e){\n\t\t\t\/\/console.log('focusout'+this);\n\t\t\tcurrent_lookup_field = '26';\n\t\t\tcurrent_lookup_form = '57';\n\t\t});\n\t\t\n\t\t\n\t});\n}else{\n\tconsole.log('jQuery check (gform_field_content_loqate_address_lookup)');\n}\t\n<\/script><\/fieldset><fieldset id=\"field_57_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full large_label contact-preferences field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Would you like to keep in touch by email?<\/legend><div class='gfield_description' id='gfield_description_57_29'>We'd love to keep in touch to give you health and lifestyle tips, updates on our work, fundraising activities and other ways you can get involved.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_57_29'><div class='gchoice gchoice_57_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='I am happy to be contacted by email'  id='choice_57_29_1'   aria-describedby=\"gfield_description_57_29\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_57_29_1' id='label_57_29_1' class='gform-field-label gform-field-label--type-inline'>I am happy to be contacted by email<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><!-- end --><\/fieldset><fieldset id=\"field_57_25\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full contact-preferences form gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><!-- start --><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_57_25'>\n                            \n                            <span id='input_57_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_57_25_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                            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