{"id":75,"date":"2020-07-04T15:06:09","date_gmt":"2020-07-04T15:06:09","guid":{"rendered":"http:\/\/3.10.170.57\/?page_id=75"},"modified":"2026-10-29T21:14:26","modified_gmt":"2026-10-29T21:14:26","slug":"adult-questionnaire","status":"publish","type":"page","link":"https:\/\/www.sophieroseoptometry.co.uk\/?page_id=75","title":{"rendered":"Adult Questionnaire"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><style id=\"wpforms-css-vars-358\">\n\t\t\t\t#wpforms-358 {\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-358\"><form id=\"wpforms-form-358\" class=\"wpforms-validate wpforms-form\" data-formid=\"358\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F75\" data-token=\"ec7744916f38559bd32d5686225f82af\" data-token-time=\"1793357392\"><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=\"8\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" data-page-2-title=\"Reason for Referral\" data-page-3-title=\"History\"><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 8<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:12.5%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-358-field_19-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"19\"><\/div><div id=\"wpforms-358-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"21\"><h3 id=\"wpforms-358-field_21\" aria-errormessage=\"wpforms-358-field_21-error\">About You<\/h3><\/div><div id=\"wpforms-358-field_8-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"8\"><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-358-field_8\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][8][first]\" aria-errormessage=\"wpforms-358-field_8-error\" required><label for=\"wpforms-358-field_8\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-358-field_8-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][8][last]\" aria-errormessage=\"wpforms-358-field_8-last-error\" required><label for=\"wpforms-358-field_8-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-358-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"13\"><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][13][date][d]\" id=\"wpforms-358-field_13-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][13][date][m]\" id=\"wpforms-358-field_13-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][13][date][y]\" id=\"wpforms-358-field_13-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-358-field_14-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-358-field_14\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][14][address1]\" aria-errormessage=\"wpforms-358-field_14-error\" required><label for=\"wpforms-358-field_14\" 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-358-field_14-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][14][city]\" aria-errormessage=\"wpforms-358-field_14-city-error\" required><label for=\"wpforms-358-field_14-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-358-field_14-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][14][state]\" aria-errormessage=\"wpforms-358-field_14-state-error\" required><label for=\"wpforms-358-field_14-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-358-field_14-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][14][postal]\" aria-errormessage=\"wpforms-358-field_14-postal-error\" required><label for=\"wpforms-358-field_14-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-358-field_15-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_15\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-358-field_15\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][15]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-358-field_15-error\" required><\/div><div id=\"wpforms-358-field_16-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_16\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-358-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" spellcheck=\"false\" aria-errormessage=\"wpforms-358-field_16-error\" required><\/div><div id=\"wpforms-358-field_102-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"102\"><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-358-field_102\" 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][102][date]\" aria-errormessage=\"wpforms-358-field_102-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-358-field_102\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-358-field_102-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][102][time]\" aria-errormessage=\"wpforms-358-field_102-time-error\" ><label for=\"wpforms-358-field_102-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-358-field_18-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"18\"><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=\"358\" 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-358-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"22\"><h3 id=\"wpforms-358-field_22\" aria-errormessage=\"wpforms-358-field_22-error\">Reason for Referral<\/h3><\/div><div id=\"wpforms-358-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_23\">Who suggested that you be seen by a behavioural optometrist?<\/label><input type=\"text\" id=\"wpforms-358-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-358-field_23-error\" ><\/div><div id=\"wpforms-358-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_24\">Why?<\/label><input type=\"text\" id=\"wpforms-358-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-358-field_24-error\" ><\/div><div id=\"wpforms-358-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_25\">What do you feel are your main difficulties and concerns?<\/label><textarea id=\"wpforms-358-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-358-field_25-error\" ><\/textarea><\/div><div id=\"wpforms-358-field_26-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">Have any other tests been carried out by Clinical Psychologist\/Occupational Therapist\/Neuro or Sports-physio Therapist\/Neurologist?<\/legend><ul id=\"wpforms-358-field_26\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_26_1\" name=\"wpforms[fields][26]\" value=\"Yes\" aria-errormessage=\"wpforms-358-field_26_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_26_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_26_2\" name=\"wpforms[fields][26]\" value=\"No\" aria-errormessage=\"wpforms-358-field_26_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_26_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_27-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"27\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_27\">Please give details of date of reports and send copies of report to read before appointment<\/label><textarea id=\"wpforms-358-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-358-field_27-error\" ><\/textarea><\/div><div id=\"wpforms-358-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_28\">Is there any further information on general health or issues you have concerns about?<\/label><textarea id=\"wpforms-358-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-358-field_28-error\" aria-describedby=\"wpforms-358-field_28-description\" ><\/textarea><div id=\"wpforms-358-field_28-description\" class=\"wpforms-field-description\">Please include any episodes of concussion or brain injury <\/div><\/div><div id=\"wpforms-358-field_30-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"30\"><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=\"358\" 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=\"358\" 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-358-field_31-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"31\"><h3 id=\"wpforms-358-field_31\" aria-errormessage=\"wpforms-358-field_31-error\">History<\/h3><\/div><div id=\"wpforms-358-field_32-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Do you have spectacles?<\/legend><ul id=\"wpforms-358-field_32\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_32_1\" name=\"wpforms[fields][32]\" value=\"Yes\" aria-errormessage=\"wpforms-358-field_32_1-error\" aria-describedby=\"wpforms-358-field_32-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_32_2\" name=\"wpforms[fields][32]\" value=\"No\" aria-errormessage=\"wpforms-358-field_32_2-error\" aria-describedby=\"wpforms-358-field_32-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_32_2\">No<\/label><\/li><\/ul><div id=\"wpforms-358-field_32-description\" class=\"wpforms-field-description\">If yes please email me a copy of the prescription before your appointment.<\/div><\/fieldset><\/div><div id=\"wpforms-358-field_96-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">When was your last eye examination?<\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][96][date][d]\" id=\"wpforms-358-field_96-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><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][96][date][m]\" id=\"wpforms-358-field_96-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><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][96][date][y]\" id=\"wpforms-358-field_96-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><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-358-field_34-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"34\"><fieldset><legend class=\"wpforms-field-label\">Have you needed to see the hospital or orthoptist about your eyes?<\/legend><ul id=\"wpforms-358-field_34\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_34_1\" name=\"wpforms[fields][34]\" value=\"Yes\" aria-errormessage=\"wpforms-358-field_34_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_34_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_34_2\" name=\"wpforms[fields][34]\" value=\"No\" aria-errormessage=\"wpforms-358-field_34_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_34_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_97-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"textarea\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_97\">Please give further details of hospital\/orthoptist appointments and\/or treatments:<\/label><textarea id=\"wpforms-358-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-358-field_97-error\" ><\/textarea><\/div><div id=\"wpforms-358-field_35-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Is there any family history of a lazy eye?<\/legend><ul id=\"wpforms-358-field_35\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_35_1\" name=\"wpforms[fields][35]\" value=\"Yes\" aria-errormessage=\"wpforms-358-field_35_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_35_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_35_2\" name=\"wpforms[fields][35]\" value=\"No\" aria-errormessage=\"wpforms-358-field_35_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_35_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_36-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Is there any history of learning or reading problems in the close family?<\/legend><ul id=\"wpforms-358-field_36\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_36_1\" name=\"wpforms[fields][36]\" value=\"Yes\" aria-errormessage=\"wpforms-358-field_36_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_36_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_36_2\" name=\"wpforms[fields][36]\" value=\"No\" aria-errormessage=\"wpforms-358-field_36_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_36_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_37-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Are you right\/left handed or ambidextrous?<\/legend><ul id=\"wpforms-358-field_37\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_37_1\" name=\"wpforms[fields][37]\" value=\"Right handed\" aria-errormessage=\"wpforms-358-field_37_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_37_1\">Right handed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_37_2\" name=\"wpforms[fields][37]\" value=\"Left handed\" aria-errormessage=\"wpforms-358-field_37_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_37_2\">Left handed<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_37_3\" name=\"wpforms[fields][37]\" value=\"Ambidextrous\" aria-errormessage=\"wpforms-358-field_37_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_37_3\">Ambidextrous<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_38-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"38\"><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=\"358\" 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=\"358\" 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-358-field_39-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"39\"><h3 id=\"wpforms-358-field_39\" aria-errormessage=\"wpforms-358-field_39-error\" aria-describedby=\"wpforms-358-field_39-description\">Visual Symptoms Checklist<\/h3><div id=\"wpforms-358-field_39-description\" class=\"wpforms-field-description\">Please indicate below the frequency of your symptoms.\nIf never, leave blank. <\/div><\/div><div id=\"wpforms-358-field_40-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Difficulty keeping your place<\/legend><ul id=\"wpforms-358-field_40\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_40_1\" name=\"wpforms[fields][40]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_40_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_40_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_40_2\" name=\"wpforms[fields][40]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_40_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_40_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Skipping or re-reading lines<\/legend><ul id=\"wpforms-358-field_41\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_41_4\" name=\"wpforms[fields][41]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_41_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_41_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_41_5\" name=\"wpforms[fields][41]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_41_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_41_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_42-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Omitting words<\/legend><ul id=\"wpforms-358-field_42\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_42_4\" name=\"wpforms[fields][42]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_42_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_42_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_42_5\" name=\"wpforms[fields][42]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_42_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_42_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_43-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label\">Word by word reading<\/legend><ul id=\"wpforms-358-field_43\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_43_4\" name=\"wpforms[fields][43]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_43_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_43_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_43_5\" name=\"wpforms[fields][43]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_43_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_43_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Difficulty remembering what you have read<\/legend><ul id=\"wpforms-358-field_44\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_44_4\" name=\"wpforms[fields][44]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_44_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_44_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_44_5\" name=\"wpforms[fields][44]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_44_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_44_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">Excessive head turning<\/legend><ul id=\"wpforms-358-field_45\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_45_4\" name=\"wpforms[fields][45]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_45_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_45_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_45_5\" name=\"wpforms[fields][45]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_45_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_45_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_46-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">Tilting head<\/legend><ul id=\"wpforms-358-field_46\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_46_4\" name=\"wpforms[fields][46]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_46_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_46_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_46_5\" name=\"wpforms[fields][46]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_46_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_46_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"47\"><fieldset><legend class=\"wpforms-field-label\">Poor sitting posture<\/legend><ul id=\"wpforms-358-field_47\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_47_4\" name=\"wpforms[fields][47]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_47_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_47_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_47_5\" name=\"wpforms[fields][47]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_47_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_47_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_48-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">Holding head close to the page<\/legend><ul id=\"wpforms-358-field_48\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_48_1\" name=\"wpforms[fields][48]\" value=\"Occasionally \" aria-errormessage=\"wpforms-358-field_48_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_48_1\">Occasionally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_48_2\" name=\"wpforms[fields][48]\" value=\"Frequently \" aria-errormessage=\"wpforms-358-field_48_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_48_2\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_49-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"49\"><fieldset><legend class=\"wpforms-field-label\">Closing or covering one eye<\/legend><ul id=\"wpforms-358-field_49\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_49_4\" name=\"wpforms[fields][49]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_49_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_49_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_49_5\" name=\"wpforms[fields][49]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_49_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_49_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_50-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Rubbing eyes during or after reading<\/legend><ul id=\"wpforms-358-field_50\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_50_4\" name=\"wpforms[fields][50]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_50_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_50_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_50_5\" name=\"wpforms[fields][50]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_50_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_50_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_51-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"51\"><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-358-field_51\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_51_4\" name=\"wpforms[fields][51]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_51_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_51_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_51_5\" name=\"wpforms[fields][51]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_51_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_51_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_52-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Short attention span<\/legend><ul id=\"wpforms-358-field_52\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_52_4\" name=\"wpforms[fields][52]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_52_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_52_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_52_5\" name=\"wpforms[fields][52]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_52_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_52_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Avoiding reading<\/legend><ul id=\"wpforms-358-field_53\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_53_4\" name=\"wpforms[fields][53]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_53_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_53_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_53_5\" name=\"wpforms[fields][53]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_53_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_53_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_54-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Reversing words, letters and\/or numbers<\/legend><ul id=\"wpforms-358-field_54\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_54_4\" name=\"wpforms[fields][54]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_54_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_54_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_54_5\" name=\"wpforms[fields][54]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_54_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_54_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_55-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Letters and\/or words appear to fade, move, or shimmer<\/legend><ul id=\"wpforms-358-field_55\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_55_4\" name=\"wpforms[fields][55]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_55_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_55_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_55_5\" name=\"wpforms[fields][55]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_55_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_55_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_56-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Words seem to double or shadow<\/legend><ul id=\"wpforms-358-field_56\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_56_4\" name=\"wpforms[fields][56]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_56_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_56_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_56_5\" name=\"wpforms[fields][56]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_56_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_56_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Please tick whichever of the following apply when doing close work:<\/legend><ul id=\"wpforms-358-field_57\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-358-field_57_4\" name=\"wpforms[fields][57][]\" value=\"Frowning\" aria-errormessage=\"wpforms-358-field_57_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_57_4\">Frowning<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-358-field_57_5\" name=\"wpforms[fields][57][]\" value=\"Blinking\" aria-errormessage=\"wpforms-358-field_57_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_57_5\">Blinking<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-358-field_57_6\" name=\"wpforms[fields][57][]\" value=\"Squinting\" aria-errormessage=\"wpforms-358-field_57_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_57_6\">Squinting<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-358-field_57_7\" name=\"wpforms[fields][57][]\" value=\"Other facial expressions\" aria-errormessage=\"wpforms-358-field_57_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_57_7\">Other facial expressions<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-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=\"4\" data-formid=\"358\" 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=\"358\" 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-358-field_67-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"67\"><h3 id=\"wpforms-358-field_67\" aria-errormessage=\"wpforms-358-field_67-error\">Body posture and Space Awareness:<\/h3><\/div><div id=\"wpforms-358-field_62-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"62\"><fieldset><legend class=\"wpforms-field-label\">Unusual Awkwardness<\/legend><ul id=\"wpforms-358-field_62\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_62_4\" name=\"wpforms[fields][62]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_62_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_62_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_62_5\" name=\"wpforms[fields][62]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_62_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_62_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_63-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">Frequent tripping and stumbling<\/legend><ul id=\"wpforms-358-field_63\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_63_4\" name=\"wpforms[fields][63]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_63_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_63_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_63_5\" name=\"wpforms[fields][63]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_63_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_63_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_64-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Knocking things off table\/desk<\/legend><ul id=\"wpforms-358-field_64\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_64_4\" name=\"wpforms[fields][64]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_64_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_64_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_64_5\" name=\"wpforms[fields][64]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_64_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_64_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Difficulty with catching\/throwing<\/legend><ul id=\"wpforms-358-field_65\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_65_4\" name=\"wpforms[fields][65]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_65_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_65_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_65_5\" name=\"wpforms[fields][65]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_65_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_66-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\">Confusing right and left<\/legend><ul id=\"wpforms-358-field_66\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_66_4\" name=\"wpforms[fields][66]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_66_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_66_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_66_5\" name=\"wpforms[fields][66]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_66_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_66_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_69-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"69\"><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=\"358\" 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=\"358\" 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-358-field_70-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"70\"><h3 id=\"wpforms-358-field_70\" aria-errormessage=\"wpforms-358-field_70-error\">General Behaviour:<\/h3><\/div><div id=\"wpforms-358-field_71-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"71\"><fieldset><legend class=\"wpforms-field-label\">Avoiding close work<\/legend><ul id=\"wpforms-358-field_71\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_71_4\" name=\"wpforms[fields][71]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_71_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_71_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_71_5\" name=\"wpforms[fields][71]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_71_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_71_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_72-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\">Distractible<\/legend><ul id=\"wpforms-358-field_72\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_72_4\" name=\"wpforms[fields][72]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_72_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_72_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_72_5\" name=\"wpforms[fields][72]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_72_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_72_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_73-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"73\"><fieldset><legend class=\"wpforms-field-label\">Unusual fatigue after close work<\/legend><ul id=\"wpforms-358-field_73\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_73_4\" name=\"wpforms[fields][73]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_73_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_73_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_73_5\" name=\"wpforms[fields][73]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_73_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_73_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_74-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"74\"><fieldset><legend class=\"wpforms-field-label\">Tension during close work, including hunching over or wriggling<\/legend><ul id=\"wpforms-358-field_74\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_74_4\" name=\"wpforms[fields][74]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_74_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_74_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_74_5\" name=\"wpforms[fields][74]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_74_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_74_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_75-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"75\"><fieldset><legend class=\"wpforms-field-label\">Headaches during\/after close work<\/legend><ul id=\"wpforms-358-field_75\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_75_4\" name=\"wpforms[fields][75]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_75_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_75_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_75_5\" name=\"wpforms[fields][75]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_75_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_75_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_76-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"76\"><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=\"358\" 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=\"358\" 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  \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-358-field_77-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"77\"><h3 id=\"wpforms-358-field_77\" aria-errormessage=\"wpforms-358-field_77-error\">Writing and Other Desk Tasks:<\/h3><\/div><div id=\"wpforms-358-field_78-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">Difficulty copying from distance to near<\/legend><ul id=\"wpforms-358-field_78\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_78_4\" name=\"wpforms[fields][78]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_78_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_78_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_78_5\" name=\"wpforms[fields][78]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_78_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_78_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\">Omitting words or phrases<\/legend><ul id=\"wpforms-358-field_79\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_79_4\" name=\"wpforms[fields][79]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_79_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_79_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_79_5\" name=\"wpforms[fields][79]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_79_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_79_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Repeating words or phrases<\/legend><ul id=\"wpforms-358-field_80\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_80_4\" name=\"wpforms[fields][80]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_80_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_80_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_80_5\" name=\"wpforms[fields][80]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_80_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_80_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_82-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"82\"><fieldset><legend class=\"wpforms-field-label\">Confusing the order of letters\t<\/legend><ul id=\"wpforms-358-field_82\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_82_4\" name=\"wpforms[fields][82]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_82_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_82_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_82_5\" name=\"wpforms[fields][82]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_82_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_82_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_83-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\">Poor handwriting<\/legend><ul id=\"wpforms-358-field_83\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_83_4\" name=\"wpforms[fields][83]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_83_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_83_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_83_5\" name=\"wpforms[fields][83]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_83_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_83_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_91-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"91\"><fieldset><legend class=\"wpforms-field-label\">Difficulty staying on the line<\/legend><ul id=\"wpforms-358-field_91\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_91_4\" name=\"wpforms[fields][91]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_91_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_91_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_91_5\" name=\"wpforms[fields][91]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_91_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_91_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_95-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Writing neatly, but slowly<\/legend><ul id=\"wpforms-358-field_95\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_95_4\" name=\"wpforms[fields][95]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_95_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_95_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_95_5\" name=\"wpforms[fields][95]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_95_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_95_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_94-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"94\"><fieldset><legend class=\"wpforms-field-label\">Reversing letters or numbers<\/legend><ul id=\"wpforms-358-field_94\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_94_4\" name=\"wpforms[fields][94]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_94_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_94_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_94_5\" name=\"wpforms[fields][94]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_94_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_94_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_92-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Getting too close to the page <\/legend><ul id=\"wpforms-358-field_92\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_92_4\" name=\"wpforms[fields][92]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_92_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_92_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_92_5\" name=\"wpforms[fields][92]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_92_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_92_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_93-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"93\"><fieldset><legend class=\"wpforms-field-label\">Tilting head to one side<\/legend><ul id=\"wpforms-358-field_93\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_93_4\" name=\"wpforms[fields][93]\" value=\"Occasionally\" aria-errormessage=\"wpforms-358-field_93_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_93_4\">Occasionally<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-358-field_93_5\" name=\"wpforms[fields][93]\" value=\"Frequently\" aria-errormessage=\"wpforms-358-field_93_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-358-field_93_5\">Frequently<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-358-field_87-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"87\"><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=\"358\" 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=\"7\" data-formid=\"358\" 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-8 last \" data-page=\"8\" style=\"display:none;\"><div id=\"wpforms-358-field_89-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-358-field_89\">Any further information you feel is useful:<\/label><textarea id=\"wpforms-358-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-358-field_89-error\" ><\/textarea><\/div><div id=\"wpforms-358-field_20-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"20\"><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=\"8\" data-formid=\"358\" 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-358-field-hp\" class=\"wpforms-field-label\">Comment<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-358-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"358\"><input type=\"hidden\" name=\"wpforms[time_token]\" value=\"1793357392.85f2f194daccb2a24fae9aae574de6482c8e3febd8ab5ab5ee516b2254c4d572\"><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\/75\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-358\" 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-75","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/75","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=75"}],"version-history":[{"count":1,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/75\/revisions"}],"predecessor-version":[{"id":373,"href":"https:\/\/www.sophieroseoptometry.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/75\/revisions\/373"}],"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=75"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}