{"id":121,"date":"2025-02-12T11:27:47","date_gmt":"2025-02-12T10:27:47","guid":{"rendered":"https:\/\/form.healwise.net\/?page_id=121"},"modified":"2025-02-12T11:27:48","modified_gmt":"2025-02-12T10:27:48","slug":"tremor-assessment-survey","status":"publish","type":"page","link":"https:\/\/form.healwise.net\/?page_id=121","title":{"rendered":"Tremor Assessment Survey"},"content":{"rendered":"<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-form-abandonment wpforms-container-save-resume wpforms-block wpforms-block-100af02f-ac1c-48af-b707-a6223349c855 wpforms-render-modern\" id=\"wpforms-118\"><form id=\"wpforms-form-118\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"118\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F121\" data-token=\"6a799f6fade4e8e48793f37976d523c8\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-118-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-118-field_5\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][5][first]\" aria-errormessage=\"wpforms-118-field_5-error\" required><label for=\"wpforms-118-field_5\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-118-field_5-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][5][last]\" aria-errormessage=\"wpforms-118-field_5-last-error\" required><label for=\"wpforms-118-field_5-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-118-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Date \/ Time<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-118-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-118-field_6-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-118-field_6\" class=\"wpforms-field-sublabel after \">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-118-field_6-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][6][time]\" aria-errormessage=\"wpforms-118-field_6-time-error\" ><label for=\"wpforms-118-field_6-time\" class=\"wpforms-field-sublabel after \">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-118-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-118-field_8\">Country of residence<\/label><input type=\"text\" id=\"wpforms-118-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-118-field_8-error\" ><\/div><div id=\"wpforms-118-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-118-field_9\">Language (please include all)<\/label><input type=\"text\" id=\"wpforms-118-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-118-field_9-error\" ><\/div><div id=\"wpforms-118-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-118-field_10\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-118-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" spellcheck=\"false\" aria-errormessage=\"wpforms-118-field_10-error\" required><\/div><div id=\"wpforms-118-field_11-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Which is your dominant hand for most\/all of your activities?<\/legend><ul id=\"wpforms-118-field_11\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_11_1\" name=\"wpforms[fields][11]\" value=\"Right\" aria-errormessage=\"wpforms-118-field_11_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_11_1\">Right<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_11_2\" name=\"wpforms[fields][11]\" value=\"Left\" aria-errormessage=\"wpforms-118-field_11_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_11_2\">Left<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_11_3\" name=\"wpforms[fields][11]\" value=\"Unsure\" aria-errormessage=\"wpforms-118-field_11_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_11_3\">Unsure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_12-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Which hand do you use for writing?<\/legend><ul id=\"wpforms-118-field_12\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_12_1\" name=\"wpforms[fields][12]\" value=\"Right\" aria-errormessage=\"wpforms-118-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_12_1\">Right<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_12_2\" name=\"wpforms[fields][12]\" value=\"Left\" aria-errormessage=\"wpforms-118-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_12_2\">Left<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_12_3\" name=\"wpforms[fields][12]\" value=\"Unsure\" aria-errormessage=\"wpforms-118-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_12_3\">Unsure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_13-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Which hand has the tremor?<\/legend><ul id=\"wpforms-118-field_13\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_13_1\" name=\"wpforms[fields][13]\" value=\"Right\" aria-errormessage=\"wpforms-118-field_13_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_13_1\">Right<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_13_2\" name=\"wpforms[fields][13]\" value=\"Left\" aria-errormessage=\"wpforms-118-field_13_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_13_2\">Left<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_13_3\" name=\"wpforms[fields][13]\" value=\"Both\" aria-errormessage=\"wpforms-118-field_13_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_13_3\">Both<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_14-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Which hand has the worst tremor?<\/legend><ul id=\"wpforms-118-field_14\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_14_1\" name=\"wpforms[fields][14]\" value=\"Right\" aria-errormessage=\"wpforms-118-field_14_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_14_1\">Right<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_14_2\" name=\"wpforms[fields][14]\" value=\"Left\" aria-errormessage=\"wpforms-118-field_14_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_14_2\">Left<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_14_3\" name=\"wpforms[fields][14]\" value=\"Unsure\" aria-errormessage=\"wpforms-118-field_14_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_14_3\">Unsure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_15-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Is your speech:<\/legend><ul id=\"wpforms-118-field_15\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_15_1\" name=\"wpforms[fields][15]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_15_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_15_2\" name=\"wpforms[fields][15]\" value=\"Mild voice tremulousness when nervous only.\" aria-errormessage=\"wpforms-118-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_15_2\">Mild voice tremulousness when nervous only.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_15_3\" name=\"wpforms[fields][15]\" value=\"Mild voice tremor, constant.\" aria-errormessage=\"wpforms-118-field_15_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_15_3\">Mild voice tremor, constant.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_15_4\" name=\"wpforms[fields][15]\" value=\"Moderate voice tremor.\" aria-errormessage=\"wpforms-118-field_15_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_15_4\">Moderate voice tremor.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_15_5\" name=\"wpforms[fields][15]\" value=\"Severe voice tremor. Some words difficult to understand.\" aria-errormessage=\"wpforms-118-field_15_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_15_5\">Severe voice tremor. Some words difficult to understand.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Feeding (other than liquids):<\/legend><ul id=\"wpforms-118-field_16\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_16_1\" name=\"wpforms[fields][16]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_16_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_16_2\" name=\"wpforms[fields][16]\" value=\"Mildly abnormal. Can bring all solids to mouth, spilling only rarely.\" aria-errormessage=\"wpforms-118-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_16_2\">Mildly abnormal. Can bring all solids to mouth, spilling only rarely.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_16_3\" name=\"wpforms[fields][16]\" value=\"Moderately abnormal. Frequent spills of peas and similar foods. May bring head at least halfway to meet food.\" aria-errormessage=\"wpforms-118-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_16_3\">Moderately abnormal. Frequent spills of peas and similar foods. May bring head at least halfway to meet food.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_16_4\" name=\"wpforms[fields][16]\" value=\"Markedly abnormal. Unable to cut or uses two hands to feed.\" aria-errormessage=\"wpforms-118-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_16_4\">Markedly abnormal. Unable to cut or uses two hands to feed.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_16_5\" name=\"wpforms[fields][16]\" value=\"Severely abnormal. Needs help to feed.\" aria-errormessage=\"wpforms-118-field_16_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_16_5\">Severely abnormal. Needs help to feed.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_17-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Bringing liquids to mouth (drinking):<\/legend><ul id=\"wpforms-118-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_17_1\" name=\"wpforms[fields][17]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_17_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_17_2\" name=\"wpforms[fields][17]\" value=\"Mildly abnormal. Can still use a spoon, but not if it is completely full.\" aria-errormessage=\"wpforms-118-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_17_2\">Mildly abnormal. Can still use a spoon, but not if it is completely full.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_17_3\" name=\"wpforms[fields][17]\" value=\"Moderately abnormal. Unable to use a spoon. Uses cup or glass.\" aria-errormessage=\"wpforms-118-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_17_3\">Moderately abnormal. Unable to use a spoon. Uses cup or glass.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_17_4\" name=\"wpforms[fields][17]\" value=\"Markedly abnormal. Can drink from cup or glass, but needs two hands.\" aria-errormessage=\"wpforms-118-field_17_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_17_4\">Markedly abnormal. Can drink from cup or glass, but needs two hands.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_17_5\" name=\"wpforms[fields][17]\" value=\"Severely abnormal. Must use a straw.\" aria-errormessage=\"wpforms-118-field_17_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_17_5\">Severely abnormal. Must use a straw.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Hygiene: (examples- washing, shaving, brushing teeth, putting on make-up, mascara and lipstick)<\/legend><ul id=\"wpforms-118-field_18\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_18_1\" name=\"wpforms[fields][18]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_18_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_18_2\" name=\"wpforms[fields][18]\" value=\"Mildly abnormal. Able to do everything, but is more careful than the average person.\" aria-errormessage=\"wpforms-118-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_18_2\">Mildly abnormal. Able to do everything, but is more careful than the average person.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_18_3\" name=\"wpforms[fields][18]\" value=\"Moderately abnormal. Able to do everything, but with errors; uses electric razor because of tremor.\" aria-errormessage=\"wpforms-118-field_18_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_18_3\">Moderately abnormal. Able to do everything, but with errors; uses electric razor because of tremor.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_18_4\" name=\"wpforms[fields][18]\" value=\"Markedly abnormal. Unable to do most fine tasks, such as putting on lipstick or shaving (even with electric shaver), unless using both hands.\" aria-errormessage=\"wpforms-118-field_18_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_18_4\">Markedly abnormal. Unable to do most fine tasks, such as putting on lipstick or shaving (even with electric shaver), unless using both hands.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_18_5\" name=\"wpforms[fields][18]\" value=\"Severely abnormal. Unable to do any fine-movement tasks.\" aria-errormessage=\"wpforms-118-field_18_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_18_5\">Severely abnormal. Unable to do any fine-movement tasks.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Dressing:<\/legend><ul id=\"wpforms-118-field_19\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_19_1\" name=\"wpforms[fields][19]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_19_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_19_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_19_2\" name=\"wpforms[fields][19]\" value=\"Mildly abnormal. Able to do everything, but is more careful than the average person\" aria-errormessage=\"wpforms-118-field_19_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_19_2\">Mildly abnormal. Able to do everything, but is more careful than the average person<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_19_3\" name=\"wpforms[fields][19]\" value=\"Moderately abnormal. Able to do everything, but with errors.\" aria-errormessage=\"wpforms-118-field_19_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_19_3\">Moderately abnormal. Able to do everything, but with errors.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_19_4\" name=\"wpforms[fields][19]\" value=\"Markedly abnormal. Needs some assistance with buttoning or other activities, such as tying shoelaces.\" aria-errormessage=\"wpforms-118-field_19_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_19_4\">Markedly abnormal. Needs some assistance with buttoning or other activities, such as tying shoelaces.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_19_5\" name=\"wpforms[fields][19]\" value=\"Severely abnormal. Requires assistance even for gross motor activities.\" aria-errormessage=\"wpforms-118-field_19_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_19_5\">Severely abnormal. Requires assistance even for gross motor activities.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_20-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Writing:<\/legend><ul id=\"wpforms-118-field_20\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_20_1\" name=\"wpforms[fields][20]\" value=\"Normal\" aria-errormessage=\"wpforms-118-field_20_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_20_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_20_2\" name=\"wpforms[fields][20]\" value=\"Mildly abnormal. Legible. Continues to write letters.\" aria-errormessage=\"wpforms-118-field_20_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_20_2\">Mildly abnormal. Legible. Continues to write letters.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_20_3\" name=\"wpforms[fields][20]\" value=\"Moderately abnormal. Legible, but no longer writes letters.\" aria-errormessage=\"wpforms-118-field_20_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_20_3\">Moderately abnormal. Legible, but no longer writes letters.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_20_4\" name=\"wpforms[fields][20]\" value=\"Markedly abnormal. Illegible.\" aria-errormessage=\"wpforms-118-field_20_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_20_4\">Markedly abnormal. Illegible.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_20_5\" name=\"wpforms[fields][20]\" value=\"Severely abnormal. Unable to sign checks or other documents requiring signature.\" aria-errormessage=\"wpforms-118-field_20_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_20_5\">Severely abnormal. Unable to sign checks or other documents requiring signature.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_21-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">Working:<\/legend><ul id=\"wpforms-118-field_21\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_21_1\" name=\"wpforms[fields][21]\" value=\"Tremor does not interfere with the job.\" aria-errormessage=\"wpforms-118-field_21_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_21_1\">Tremor does not interfere with the job.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_21_2\" name=\"wpforms[fields][21]\" value=\"Able to work, but needs to be more careful than the average person.\" aria-errormessage=\"wpforms-118-field_21_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_21_2\">Able to work, but needs to be more careful than the average person.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_21_3\" name=\"wpforms[fields][21]\" value=\"Able to do everything, but with errors. Poorer than usual performance because of tremor.\" aria-errormessage=\"wpforms-118-field_21_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_21_3\">Able to do everything, but with errors. Poorer than usual performance because of tremor.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_21_4\" name=\"wpforms[fields][21]\" value=\"Unable to do regular job. May have changed to a different job because of tremor. Tremor limits housework, such as ironing.\" aria-errormessage=\"wpforms-118-field_21_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_21_4\">Unable to do regular job. May have changed to a different job because of tremor. Tremor limits housework, such as ironing.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_21_5\" name=\"wpforms[fields][21]\" value=\"Unable to do any outside job; housework very limited.\" aria-errormessage=\"wpforms-118-field_21_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_21_5\">Unable to do any outside job; housework very limited.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-118-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-118-field_22\">What is your occupation?<\/label><input type=\"text\" id=\"wpforms-118-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-118-field_22-error\" ><\/div><div id=\"wpforms-118-field_23-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Social activities:<\/legend><ul id=\"wpforms-118-field_23\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_23_1\" name=\"wpforms[fields][23]\" value=\"No changes\" aria-errormessage=\"wpforms-118-field_23_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_23_1\">No changes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_23_2\" name=\"wpforms[fields][23]\" value=\"Minimal change in social activities, still socializes.\" aria-errormessage=\"wpforms-118-field_23_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_23_2\">Minimal change in social activities, still socializes.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_23_3\" name=\"wpforms[fields][23]\" value=\"Moderate change in social activities, avoids encounters with strangers.\" aria-errormessage=\"wpforms-118-field_23_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_23_3\">Moderate change in social activities, avoids encounters with strangers.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_23_4\" name=\"wpforms[fields][23]\" value=\"Marked change in social activities, avoids encounters with friends.\" aria-errormessage=\"wpforms-118-field_23_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_23_4\">Marked change in social activities, avoids encounters with friends.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-118-field_23_5\" name=\"wpforms[fields][23]\" value=\"Severe change in social activities, avoid any public encounters.\" aria-errormessage=\"wpforms-118-field_23_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-118-field_23_5\">Severe change in social activities, avoid any public encounters.<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"118\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-118\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit Survey\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit Survey<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/form.healwise.net\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-121","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS<\/title>\n<meta name=\"description\" content=\"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts\" \/>\n<meta name=\"robots\" content=\"noindex, follow\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS\" \/>\n<meta property=\"og:description\" content=\"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts\" \/>\n<meta property=\"og:url\" content=\"https:\/\/form.healwise.net\/?page_id=121\" \/>\n<meta property=\"og:site_name\" content=\"Healwise Form\" \/>\n<meta property=\"article:modified_time\" content=\"2025-02-12T10:27:48+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/form.healwise.net\/?page_id=121\",\"url\":\"https:\/\/form.healwise.net\/?page_id=121\",\"name\":\"Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS\",\"isPartOf\":{\"@id\":\"https:\/\/form.healwise.net\/#website\"},\"datePublished\":\"2025-02-12T10:27:47+00:00\",\"dateModified\":\"2025-02-12T10:27:48+00:00\",\"description\":\"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts\",\"breadcrumb\":{\"@id\":\"https:\/\/form.healwise.net\/?page_id=121#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/form.healwise.net\/?page_id=121\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/form.healwise.net\/?page_id=121#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/form.healwise.net\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Tremor Assessment Survey\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/form.healwise.net\/#website\",\"url\":\"https:\/\/form.healwise.net\/\",\"name\":\"Healwise Form\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/form.healwise.net\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS","description":"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts","robots":{"index":"noindex","follow":"follow"},"og_locale":"en_US","og_type":"article","og_title":"Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS","og_description":"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts","og_url":"https:\/\/form.healwise.net\/?page_id=121","og_site_name":"Healwise Form","article_modified_time":"2025-02-12T10:27:48+00:00","twitter_card":"summary_large_image","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/form.healwise.net\/?page_id=121","url":"https:\/\/form.healwise.net\/?page_id=121","name":"Tremor Assessment Survey - Healwise FormTremor Assessment Survey | Healwise MRgFUS","isPartOf":{"@id":"https:\/\/form.healwise.net\/#website"},"datePublished":"2025-02-12T10:27:47+00:00","dateModified":"2025-02-12T10:27:48+00:00","description":"Take our tremor eligibility survey to assess symptoms and find treatment options. Quick, confidential, and reviewed by experts","breadcrumb":{"@id":"https:\/\/form.healwise.net\/?page_id=121#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/form.healwise.net\/?page_id=121"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/form.healwise.net\/?page_id=121#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/form.healwise.net\/"},{"@type":"ListItem","position":2,"name":"Tremor Assessment Survey"}]},{"@type":"WebSite","@id":"https:\/\/form.healwise.net\/#website","url":"https:\/\/form.healwise.net\/","name":"Healwise Form","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/form.healwise.net\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/pages\/121","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/form.healwise.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=121"}],"version-history":[{"count":1,"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/pages\/121\/revisions"}],"predecessor-version":[{"id":124,"href":"https:\/\/form.healwise.net\/index.php?rest_route=\/wp\/v2\/pages\/121\/revisions\/124"}],"wp:attachment":[{"href":"https:\/\/form.healwise.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=121"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}