{"id":72,"date":"2020-07-04T15:00:49","date_gmt":"2020-07-04T15:00:49","guid":{"rendered":"http:\/\/3.10.170.57\/?page_id=72"},"modified":"2026-10-29T21:15:03","modified_gmt":"2026-10-29T21:15:03","slug":"child-questionnaire","status":"publish","type":"page","link":"https:\/\/www.sophieroseoptometry.co.uk\/?page_id=72","title":{"rendered":"Child Questionnaire"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><style id=\"wpforms-css-vars-360\">\n\t\t\t\t#wpforms-360 {\n\t\t\t\t--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--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-360\"><form id=\"wpforms-form-360\" class=\"wpforms-validate wpforms-form\" data-formid=\"360\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F72\" data-token=\"471cfcd0205552d9c41b3dd8e98d2ee8\" data-token-time=\"1793357315\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"7\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" data-page-1-title=\"About You\" data-page-2-title=\"Reason for Referral\" data-page-3-title=\"Developmental History\" data-page-4-title=\"Visual History\" data-page-5-title=\"Visual Symptoms Checklist\" data-page-6-title=\"Visual Symptoms Checklist\" data-page-7-title=\"Other Comments\">About You<\/span><span class=\"wpforms-page-indicator-page-title-sep\" > - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 7<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:14.285714285714%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-360-field_48-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"48\"><\/div><div id=\"wpforms-360-field_40-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Child&#039;s\/Student&#039;s 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-360-field_40\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][40][first]\" aria-errormessage=\"wpforms-360-field_40-error\" required><label for=\"wpforms-360-field_40\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-360-field_40-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][40][last]\" aria-errormessage=\"wpforms-360-field_40-last-error\" required><label for=\"wpforms-360-field_40-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_41-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][41][date][d]\" id=\"wpforms-360-field_41-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][41][date][m]\" id=\"wpforms-360-field_41-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][41][date][y]\" id=\"wpforms-360-field_41-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_42-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Address (or school address if being filled in by teacher) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-360-field_42\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][42][address1]\" aria-errormessage=\"wpforms-360-field_42-error\" required><label for=\"wpforms-360-field_42\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-360-field_42-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][42][city]\" aria-errormessage=\"wpforms-360-field_42-city-error\" required><label for=\"wpforms-360-field_42-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-360-field_42-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][42][state]\" aria-errormessage=\"wpforms-360-field_42-state-error\" required><label for=\"wpforms-360-field_42-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-360-field_42-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][42][postal]\" aria-errormessage=\"wpforms-360-field_42-postal-error\" required><label for=\"wpforms-360-field_42-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_43-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_43\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-360-field_43\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][43]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-360-field_43-error\" required><\/div><div id=\"wpforms-360-field_44-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_44\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-360-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" spellcheck=\"false\" aria-errormessage=\"wpforms-360-field_44-error\" required><\/div><div id=\"wpforms-360-field_45-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">Parent&#039;s\/Guardian Name (1) <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-360-field_45\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][45][first]\" aria-errormessage=\"wpforms-360-field_45-error\" required><label for=\"wpforms-360-field_45\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-360-field_45-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][45][last]\" aria-errormessage=\"wpforms-360-field_45-last-error\" required><label for=\"wpforms-360-field_45-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_150-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"150\"><fieldset><legend class=\"wpforms-field-label\">Parent&#039;s\/Guardian Name (2) <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-360-field_150\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][150][first]\" aria-errormessage=\"wpforms-360-field_150-error\" required><label for=\"wpforms-360-field_150\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-360-field_150-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][150][last]\" aria-errormessage=\"wpforms-360-field_150-last-error\" required><label for=\"wpforms-360-field_150-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_46-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">Date and Time of our Appointment (if booked)<\/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-360-field_46\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][46][date]\" aria-errormessage=\"wpforms-360-field_46-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-360-field_46\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-360-field_46-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][46][time]\" aria-errormessage=\"wpforms-360-field_46-time-error\" ><label for=\"wpforms-360-field_46-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-360-field_47-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"47\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-360-field_139-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"139\"><h3 id=\"wpforms-360-field_139\" aria-errormessage=\"wpforms-360-field_139-error\">Reason for Referral<\/h3><\/div><div id=\"wpforms-360-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_50\">Who recommended that your child be seen by a behavioural optometrist?<\/label><input type=\"text\" id=\"wpforms-360-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" aria-errormessage=\"wpforms-360-field_50-error\" ><\/div><div id=\"wpforms-360-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_51\">Why?<\/label><input type=\"text\" id=\"wpforms-360-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-360-field_51-error\" ><\/div><div id=\"wpforms-360-field_52-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_52\">What do you feel are your child&#039;s main difficulties and your concerns?<\/label><textarea id=\"wpforms-360-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-360-field_52-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_53\">Which school does your child attend?<\/label><input type=\"text\" id=\"wpforms-360-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-360-field_53-error\" ><\/div><div id=\"wpforms-360-field_54-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_54\">Have your child&#039;s school expressed any concerns about his\/her progress, if so what?<\/label><textarea id=\"wpforms-360-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-360-field_54-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_55-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Have any other tests been carried out by SENCo\/Educational Psychologist\/Occupational Therapist\/ Speech and Language therapist?<\/legend><ul id=\"wpforms-360-field_55\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_55_1\" name=\"wpforms[fields][55]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_55_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_55_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_55_2\" name=\"wpforms[fields][55]\" value=\"No\" aria-errormessage=\"wpforms-360-field_55_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_55_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_56-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_56\"> Please give more dates, details and send me a copy of report to read before appointment<\/label><textarea id=\"wpforms-360-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-360-field_56-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_60-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_60\">Are there any other factors, or further information you feel would be of help to us?<\/label><textarea id=\"wpforms-360-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-360-field_60-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_61-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"61\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-360-field_138-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"138\"><h3 id=\"wpforms-360-field_138\" aria-errormessage=\"wpforms-360-field_138-error\">Developmental History<\/h3><\/div><div id=\"wpforms-360-field_152-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"152\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_152\">Were there any complications or difficulties during pregnancy or at birth?<\/label><textarea id=\"wpforms-360-field_152\" class=\"wpforms-field-medium\" name=\"wpforms[fields][152]\" aria-errormessage=\"wpforms-360-field_152-error\" aria-describedby=\"wpforms-360-field_152-description\" ><\/textarea><div id=\"wpforms-360-field_152-description\" class=\"wpforms-field-description\">If yes, please give details.<\/div><\/div><div id=\"wpforms-360-field_63-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">Was your child born by caesarean section?<\/legend><ul id=\"wpforms-360-field_63\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_63_1\" name=\"wpforms[fields][63]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_63_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_63_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_63_2\" name=\"wpforms[fields][63]\" value=\"No\" aria-errormessage=\"wpforms-360-field_63_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_63_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_64-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Was birth premature?<\/legend><ul id=\"wpforms-360-field_64\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_64_1\" name=\"wpforms[fields][64]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_64_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_64_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_64_2\" name=\"wpforms[fields][64]\" value=\"No\" aria-errormessage=\"wpforms-360-field_64_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_64_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Was birth weight low?<\/legend><ul id=\"wpforms-360-field_65\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_65_1\" name=\"wpforms[fields][65]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_65_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_65_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_65_2\" name=\"wpforms[fields][65]\" value=\"No\" aria-errormessage=\"wpforms-360-field_65_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_65_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_66-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_66\">Has your child had\/have problems with glue ear or grommets used?<\/label><input type=\"text\" id=\"wpforms-360-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" aria-errormessage=\"wpforms-360-field_66-error\" ><\/div><div id=\"wpforms-360-field_67-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_67\">Do you feel your child has a hearing problem or finds sequences of instructions difficult to follow?<\/label><input type=\"text\" id=\"wpforms-360-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\" aria-errormessage=\"wpforms-360-field_67-error\" ><\/div><div id=\"wpforms-360-field_153-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_153\">Does your child have any health problems?<\/label><textarea id=\"wpforms-360-field_153\" class=\"wpforms-field-medium\" name=\"wpforms[fields][153]\" aria-errormessage=\"wpforms-360-field_153-error\" aria-describedby=\"wpforms-360-field_153-description\" ><\/textarea><div id=\"wpforms-360-field_153-description\" class=\"wpforms-field-description\">If yes, please give details, especially regarding concussions.<\/div><\/div><div id=\"wpforms-360-field_154-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"154\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_154\">Does your child suffer from any allergies?<\/label><textarea id=\"wpforms-360-field_154\" class=\"wpforms-field-medium\" name=\"wpforms[fields][154]\" aria-errormessage=\"wpforms-360-field_154-error\" aria-describedby=\"wpforms-360-field_154-description\" ><\/textarea><div id=\"wpforms-360-field_154-description\" class=\"wpforms-field-description\">If yes, please give details.<\/div><\/div><div id=\"wpforms-360-field_72-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_72\">At what age did your child crawl, and was crawling normal?<\/label><input type=\"text\" id=\"wpforms-360-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" aria-errormessage=\"wpforms-360-field_72-error\" ><\/div><div id=\"wpforms-360-field_73-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_73\">At what age did your child walk?<\/label><input type=\"text\" id=\"wpforms-360-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" aria-errormessage=\"wpforms-360-field_73-error\" ><\/div><div id=\"wpforms-360-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_74\">At what age did your child talk?<\/label><input type=\"text\" id=\"wpforms-360-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" aria-errormessage=\"wpforms-360-field_74-error\" ><\/div><div id=\"wpforms-360-field_75-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"75\"><fieldset><legend class=\"wpforms-field-label\"> Is your child right\/left handed or ambidextrous?<\/legend><ul id=\"wpforms-360-field_75\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_75_1\" name=\"wpforms[fields][75]\" value=\"Right Handed\" aria-errormessage=\"wpforms-360-field_75_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_75_1\">Right Handed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_75_2\" name=\"wpforms[fields][75]\" value=\"Left Handed\" aria-errormessage=\"wpforms-360-field_75_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_75_2\">Left Handed<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_75_3\" name=\"wpforms[fields][75]\" value=\"Ambidextrous\" aria-errormessage=\"wpforms-360-field_75_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_75_3\">Ambidextrous<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_77-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_77\">Are you concerned about their attention levels and or is ADHD or ADD a suspicion? <\/label><textarea id=\"wpforms-360-field_77\" class=\"wpforms-field-medium\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-360-field_77-error\" aria-describedby=\"wpforms-360-field_77-description\" ><\/textarea><div id=\"wpforms-360-field_77-description\" class=\"wpforms-field-description\">If yes, please give details.<\/div><\/div><div id=\"wpforms-360-field_78-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_78\">Is there any history of learning or reading problems, Aspergers or other autism, dyspraxia in the close family?<\/label><input type=\"text\" id=\"wpforms-360-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-360-field_78-error\" ><\/div><div id=\"wpforms-360-field_79-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"79\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-360-field_137-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"137\"><h3 id=\"wpforms-360-field_137\" aria-errormessage=\"wpforms-360-field_137-error\">Visual History<\/h3><\/div><div id=\"wpforms-360-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Does your child have spectacles?<\/legend><ul id=\"wpforms-360-field_80\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_80_1\" name=\"wpforms[fields][80]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_80_1-error\" aria-describedby=\"wpforms-360-field_80-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_80_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_80_2\" name=\"wpforms[fields][80]\" value=\"No\" aria-errormessage=\"wpforms-360-field_80_2-error\" aria-describedby=\"wpforms-360-field_80-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_80_2\">No<\/label><\/li><\/ul><div id=\"wpforms-360-field_80-description\" class=\"wpforms-field-description\">If yes, email a copy of prescription prior to our appointment.<\/div><\/fieldset><\/div><div id=\"wpforms-360-field_155-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"155\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_155\">When was their last eye examination?<\/label><input type=\"text\" id=\"wpforms-360-field_155\" class=\"wpforms-field-medium\" name=\"wpforms[fields][155]\" aria-errormessage=\"wpforms-360-field_155-error\" ><\/div><div id=\"wpforms-360-field_83-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\"> Have they needed to see the hospital or orthoptist about their eyes?<\/legend><ul id=\"wpforms-360-field_83\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_83_1\" name=\"wpforms[fields][83]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_83_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_83_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_83_2\" name=\"wpforms[fields][83]\" value=\"No\" aria-errormessage=\"wpforms-360-field_83_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_83_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_156-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"156\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_156\">Please give details:<\/label><textarea id=\"wpforms-360-field_156\" class=\"wpforms-field-medium\" name=\"wpforms[fields][156]\" aria-errormessage=\"wpforms-360-field_156-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_84-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"84\"><fieldset><legend class=\"wpforms-field-label\">Is there any close family history of spectacles or a lazy eye?<\/legend><ul id=\"wpforms-360-field_84\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_84_1\" name=\"wpforms[fields][84]\" value=\"Yes\" aria-errormessage=\"wpforms-360-field_84_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_84_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_84_2\" name=\"wpforms[fields][84]\" value=\"No\" aria-errormessage=\"wpforms-360-field_84_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_84_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_157-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"157\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_157\">Please give details:<\/label><input type=\"text\" id=\"wpforms-360-field_157\" class=\"wpforms-field-medium\" name=\"wpforms[fields][157]\" aria-errormessage=\"wpforms-360-field_157-error\" ><\/div><div id=\"wpforms-360-field_85-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"85\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"4\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-360-field_136-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"136\"><h3 id=\"wpforms-360-field_136\" aria-errormessage=\"wpforms-360-field_136-error\" aria-describedby=\"wpforms-360-field_136-description\">Visual Symptoms Checklist<\/h3><div id=\"wpforms-360-field_136-description\" class=\"wpforms-field-description\">Please indicate below the frequency of their symptoms. If never, please leave blank.<\/div><\/div><div id=\"wpforms-360-field_135-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"135\"><h3 id=\"wpforms-360-field_135\" aria-errormessage=\"wpforms-360-field_135-error\">Reading<\/h3><\/div><div id=\"wpforms-360-field_86-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-two-fourths wpforms-first wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"86\"><fieldset><legend class=\"wpforms-field-label\">Difficulty keeping place<\/legend><ul id=\"wpforms-360-field_86\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_86_4\" name=\"wpforms[fields][86]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_86_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_86_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_86_5\" name=\"wpforms[fields][86]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_86_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_86_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_87-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-two-fourths wpforms-first wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"87\"><fieldset><legend class=\"wpforms-field-label\">Skips or rereads lines<\/legend><ul id=\"wpforms-360-field_87\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_87_4\" name=\"wpforms[fields][87]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_87_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_87_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_87_5\" name=\"wpforms[fields][87]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_87_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_87_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_88-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Omits words<\/legend><ul id=\"wpforms-360-field_88\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_88_4\" name=\"wpforms[fields][88]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_88_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_88_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_88_5\" name=\"wpforms[fields][88]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_88_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_88_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_158-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"158\"><fieldset><legend class=\"wpforms-field-label\">Confuses word, letter or number order<\/legend><ul id=\"wpforms-360-field_158\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_158_4\" name=\"wpforms[fields][158]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_158_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_158_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_158_5\" name=\"wpforms[fields][158]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_158_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_158_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_89-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"89\"><fieldset><legend class=\"wpforms-field-label\">Word by word reading<\/legend><ul id=\"wpforms-360-field_89\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_89_4\" name=\"wpforms[fields][89]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_89_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_89_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_89_5\" name=\"wpforms[fields][89]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_89_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_89_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_90-container\" class=\"wpforms-field wpforms-field-radio reading-form wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"90\"><fieldset><legend class=\"wpforms-field-label\">Difficulty remembering what they have read<\/legend><ul id=\"wpforms-360-field_90\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_90_4\" name=\"wpforms[fields][90]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_90_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_90_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_90_5\" name=\"wpforms[fields][90]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_90_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_90_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_92-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Tilts or turns head<\/legend><ul id=\"wpforms-360-field_92\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_92_4\" name=\"wpforms[fields][92]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_92_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_92_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_92_5\" name=\"wpforms[fields][92]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_92_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_92_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_93-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"93\"><fieldset><legend class=\"wpforms-field-label\">Poor sitting posture<\/legend><ul id=\"wpforms-360-field_93\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_93_4\" name=\"wpforms[fields][93]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_93_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_93_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_93_5\" name=\"wpforms[fields][93]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_93_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_93_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_94-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"94\"><fieldset><legend class=\"wpforms-field-label\">Holds head close to the page<\/legend><ul id=\"wpforms-360-field_94\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_94_4\" name=\"wpforms[fields][94]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_94_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_94_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_94_5\" name=\"wpforms[fields][94]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_94_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_94_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_95-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Closes or covers one eye<\/legend><ul id=\"wpforms-360-field_95\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_95_4\" name=\"wpforms[fields][95]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_95_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_95_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_95_5\" name=\"wpforms[fields][95]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_95_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_95_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_96-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">Rubs eyes during or after reading<\/legend><ul id=\"wpforms-360-field_96\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_96_4\" name=\"wpforms[fields][96]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_96_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_96_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_96_5\" name=\"wpforms[fields][96]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_96_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_96_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_98-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Problems with 3D movies or TV? - Fatigue\/removing 3D spectacles\/rubbing eyes\/cannot watch them\/cannot see the 3D<\/legend><ul id=\"wpforms-360-field_98\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_98_4\" name=\"wpforms[fields][98]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_98_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_98_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_98_5\" name=\"wpforms[fields][98]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_98_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_98_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_97-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Short attention span<\/legend><ul id=\"wpforms-360-field_97\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_97_4\" name=\"wpforms[fields][97]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_97_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_97_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_97_5\" name=\"wpforms[fields][97]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_97_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_97_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_99-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"99\"><fieldset><legend class=\"wpforms-field-label\">Avoids reading<\/legend><ul id=\"wpforms-360-field_99\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_99_4\" name=\"wpforms[fields][99]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_99_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_99_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_99_5\" name=\"wpforms[fields][99]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_99_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_99_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_100-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">Reverses words, letters and\/or numbers<\/legend><ul id=\"wpforms-360-field_100\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_100_4\" name=\"wpforms[fields][100]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_100_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_100_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_100_5\" name=\"wpforms[fields][100]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_100_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_100_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_101-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">Complaints of letters moving<\/legend><ul id=\"wpforms-360-field_101\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_101_4\" name=\"wpforms[fields][101]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_101_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_101_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_101_5\" name=\"wpforms[fields][101]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_101_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_101_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_159-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"159\"><fieldset><legend class=\"wpforms-field-label\">Complaints of letters fading\/shimmering<\/legend><ul id=\"wpforms-360-field_159\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_159_4\" name=\"wpforms[fields][159]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_159_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_159_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_159_5\" name=\"wpforms[fields][159]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_159_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_159_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_160-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"160\"><fieldset><legend class=\"wpforms-field-label\">Complaints of colours around letters\/words<\/legend><ul id=\"wpforms-360-field_160\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_160_4\" name=\"wpforms[fields][160]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_160_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_160_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_160_5\" name=\"wpforms[fields][160]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_160_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_160_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_161-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"161\"><fieldset><legend class=\"wpforms-field-label\">Complaints of letters shadowing or doubling <\/legend><ul id=\"wpforms-360-field_161\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_161_4\" name=\"wpforms[fields][161]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_161_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_161_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_161_5\" name=\"wpforms[fields][161]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_161_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_161_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_104-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"104\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"5\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-360-field_105-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"105\"><h3 id=\"wpforms-360-field_105\" aria-errormessage=\"wpforms-360-field_105-error\" aria-describedby=\"wpforms-360-field_105-description\">Visual Symptoms Checklist<\/h3><div id=\"wpforms-360-field_105-description\" class=\"wpforms-field-description\">Please indicate below the frequency of your symptoms.<\/div><\/div><div id=\"wpforms-360-field_106-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"106\"><h3 id=\"wpforms-360-field_106\" aria-errormessage=\"wpforms-360-field_106-error\">Body Posture and Space Awareness:<\/h3><\/div><div id=\"wpforms-360-field_107-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">Unusual Awkwardness\t<\/legend><ul id=\"wpforms-360-field_107\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_107_4\" name=\"wpforms[fields][107]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_107_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_107_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_107_5\" name=\"wpforms[fields][107]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_107_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_107_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_108-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"108\"><fieldset><legend class=\"wpforms-field-label\">Frequent tripping and stumbling<\/legend><ul id=\"wpforms-360-field_108\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_108_4\" name=\"wpforms[fields][108]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_108_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_108_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_108_5\" name=\"wpforms[fields][108]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_108_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_108_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_110-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"110\"><fieldset><legend class=\"wpforms-field-label\">Knocks things off table\/desk<\/legend><ul id=\"wpforms-360-field_110\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_110_4\" name=\"wpforms[fields][110]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_110_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_110_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_110_5\" name=\"wpforms[fields][110]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_110_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_110_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_113-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"113\"><fieldset><legend class=\"wpforms-field-label\">Difficulty with catching\/throwing<\/legend><ul id=\"wpforms-360-field_113\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_113_4\" name=\"wpforms[fields][113]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_113_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_113_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_113_5\" name=\"wpforms[fields][113]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_113_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_113_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_112-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"112\"><fieldset><legend class=\"wpforms-field-label\">Confuses right and left<\/legend><ul id=\"wpforms-360-field_112\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_112_4\" name=\"wpforms[fields][112]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_112_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_112_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_112_5\" name=\"wpforms[fields][112]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_112_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_112_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_114-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"114\"><h3 id=\"wpforms-360-field_114\" aria-errormessage=\"wpforms-360-field_114-error\">General Behaviour:<\/h3><\/div><div id=\"wpforms-360-field_115-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"115\"><fieldset><legend class=\"wpforms-field-label\">Avoiding close work<\/legend><ul id=\"wpforms-360-field_115\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_115_4\" name=\"wpforms[fields][115]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_115_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_115_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_115_5\" name=\"wpforms[fields][115]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_115_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_115_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_120-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"120\"><fieldset><legend class=\"wpforms-field-label\">Distractible<\/legend><ul id=\"wpforms-360-field_120\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_120_4\" name=\"wpforms[fields][120]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_120_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_120_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_120_5\" name=\"wpforms[fields][120]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_120_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_120_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_121-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"121\"><fieldset><legend class=\"wpforms-field-label\">Unusual fatigue after close work<\/legend><ul id=\"wpforms-360-field_121\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_121_4\" name=\"wpforms[fields][121]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_121_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_121_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_121_5\" name=\"wpforms[fields][121]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_121_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_121_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_122-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"122\"><fieldset><legend class=\"wpforms-field-label\">Tension during close work, including hunching over or wriggling<\/legend><ul id=\"wpforms-360-field_122\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_122_4\" name=\"wpforms[fields][122]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_122_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_122_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_122_5\" name=\"wpforms[fields][122]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_122_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_122_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_123-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"123\"><fieldset><legend class=\"wpforms-field-label\">Headaches during\/after close work<\/legend><ul id=\"wpforms-360-field_123\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_123_4\" name=\"wpforms[fields][123]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_123_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_123_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_123_5\" name=\"wpforms[fields][123]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_123_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_123_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_124-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"124\"><h3 id=\"wpforms-360-field_124\" aria-errormessage=\"wpforms-360-field_124-error\">Writing and Other Desk Tasks<\/h3><\/div><div id=\"wpforms-360-field_125-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"125\"><fieldset><legend class=\"wpforms-field-label\">Difficulty copying from the board<\/legend><ul id=\"wpforms-360-field_125\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_125_1\" name=\"wpforms[fields][125]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_125_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_125_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_125_2\" name=\"wpforms[fields][125]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_125_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_125_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_126-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"126\"><fieldset><legend class=\"wpforms-field-label\">Omits words or phrases<\/legend><ul id=\"wpforms-360-field_126\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_126_1\" name=\"wpforms[fields][126]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_126_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_126_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_126_2\" name=\"wpforms[fields][126]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_126_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_126_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_127-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"127\"><fieldset><legend class=\"wpforms-field-label\">Repeating words or phrases<\/legend><ul id=\"wpforms-360-field_127\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_127_1\" name=\"wpforms[fields][127]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_127_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_127_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_127_2\" name=\"wpforms[fields][127]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_127_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_127_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_128-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"128\"><fieldset><legend class=\"wpforms-field-label\">Confusing the order of letters and\/or numbers<\/legend><ul id=\"wpforms-360-field_128\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_128_1\" name=\"wpforms[fields][128]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_128_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_128_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_128_2\" name=\"wpforms[fields][128]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_128_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_128_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_129-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"129\"><fieldset><legend class=\"wpforms-field-label\">Poor handwriting<\/legend><ul id=\"wpforms-360-field_129\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_129_1\" name=\"wpforms[fields][129]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_129_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_129_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_129_2\" name=\"wpforms[fields][129]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_129_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_129_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_130-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"130\"><fieldset><legend class=\"wpforms-field-label\">Difficulty staying on the line<\/legend><ul id=\"wpforms-360-field_130\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_130_1\" name=\"wpforms[fields][130]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_130_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_130_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_130_2\" name=\"wpforms[fields][130]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_130_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_130_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_131-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"131\"><fieldset><legend class=\"wpforms-field-label\">Writing neatly, but slowly<\/legend><ul id=\"wpforms-360-field_131\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_131_1\" name=\"wpforms[fields][131]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_131_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_131_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_131_2\" name=\"wpforms[fields][131]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_131_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_131_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_132-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"132\"><fieldset><legend class=\"wpforms-field-label\">Reversing letters or numbers<\/legend><ul id=\"wpforms-360-field_132\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_132_1\" name=\"wpforms[fields][132]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_132_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_132_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_132_2\" name=\"wpforms[fields][132]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_132_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_132_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_133-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"133\"><fieldset><legend class=\"wpforms-field-label\">Holding head too close to the page<\/legend><ul id=\"wpforms-360-field_133\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_133_1\" name=\"wpforms[fields][133]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_133_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_133_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_133_2\" name=\"wpforms[fields][133]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_133_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_133_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_134-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"134\"><fieldset><legend class=\"wpforms-field-label\">Tilting head to one side<\/legend><ul id=\"wpforms-360-field_134\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_134_1\" name=\"wpforms[fields][134]\" value=\"Occasionally\" aria-errormessage=\"wpforms-360-field_134_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_134_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-360-field_134_2\" name=\"wpforms[fields][134]\" value=\"Frequently\" aria-errormessage=\"wpforms-360-field_134_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-360-field_134_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-360-field_142-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"142\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"6\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"6\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.sophieroseoptometry.co.uk\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-360-field_141-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"141\"><label class=\"wpforms-field-label\" for=\"wpforms-360-field_141\">Any further information:<\/label><textarea id=\"wpforms-360-field_141\" class=\"wpforms-field-medium\" name=\"wpforms[fields][141]\" aria-errormessage=\"wpforms-360-field_141-error\" ><\/textarea><\/div><div id=\"wpforms-360-field_49-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"49\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"7\" data-formid=\"360\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/span><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-360-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-360-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"360\"><input type=\"hidden\" name=\"wpforms[time_token]\" value=\"1793357315.c7c23ec7b6bba40c304f3414ffb7a1c38af6160d656478f737e4061aa5a5f4a3\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/72\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-360\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container --><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":77,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-72","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/72","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=72"}],"version-history":[{"count":1,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/72\/revisions"}],"predecessor-version":[{"id":374,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/72\/revisions\/374"}],"up":[{"embeddable":true,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/77"}],"wp:attachment":[{"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=72"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}