{"id":118642,"date":"2025-12-23T13:13:27","date_gmt":"2025-12-23T12:13:27","guid":{"rendered":"https:\/\/doktershuisantverpia.com\/?page_id=118642"},"modified":"2026-01-15T11:01:22","modified_gmt":"2026-01-15T10:01:22","slug":"coloscopy-gastroscopy-appointment","status":"publish","type":"page","link":"https:\/\/doktershuisantverpia.com\/en\/coloscopy-gastroscopy-appointment\/","title":{"rendered":"Making an endoscopy appointment (form)"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div data-parent=\"true\" class=\"vc_row style-color-873549-bg row-container\" id=\"row-unique-0\"><div class=\"row no-top-padding no-bottom-padding no-h-padding full-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-middle pos-center align_left column_parent col-lg-12 half-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell\" ><div class=\"uncont no-block-padding col-custom-width\" style=\" max-width:75%;\" ><div class=\"empty-space empty-double mobile-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"empty-space empty-single desktop-hidden tablet-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_row row-internal row-container\"><div class=\"row row-child\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_center column_child col-lg-12 single-internal-gutter\"><div class=\"uncol style-light\" ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" ><h1 class=\"font-146656 fontsize-208892 text-color-227611-color\" ><span>Appointment endoscopy<\/span><\/h1><\/div><div class=\"clear\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"vc_row row-internal row-container tablet-hidden mobile-hidden\"><div class=\"row col-no-gutter row-child\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_center column_child col-lg-12 padding_contactpagina1 single-internal-gutter\"><div class=\"uncol style-light\" ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-0\" data-row=\"script-row-unique-0\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-0\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row row-container\" id=\"row-unique-1\"><div class=\"row single-top-padding single-bottom-padding no-h-padding full-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_parent col-lg-12 single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div class=\"vc_row row-internal row-container\"><div class=\"row col-half-gutter row-child\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_child col-lg-6 tablet-hidden mobile-hidden col-md-33 single-internal-gutter\"><div class=\"uncol style-light sticky-element sticky-sidebar shift_x_neg_quad\" ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div id=\"gallery-1990741\" class=\"un-media-gallery cssgrid-system cssgrid-general-light grid-general-light cssgrid-804958  height_media_gallery\">\n\t\t\t\t\t\n\t\n\t<div class=\"cssgrid-wrapper grid-wrapper cssgrid-single-gutter\" >\n\t\t\t\t\t\t\t\t\t<div class=\"cssgrid-container grid-container cssgrid-layout\" >\n<div class=\"tmb tmb-no-double-tap tmb-grid tmb-iso-h4 tmb-light tmb-overlay-text-anim tmb-overlay-middle tmb-overlay-text-left tmb-id-118570  tmb-img-ratio tmb-media-first tmb-media-last tmb-content-overlay tmb-no-bg\" ><div class=\"t-inside no-anim\" ><div class=\"t-entry-visual\"><div class=\"t-entry-visual-tc\"><div class=\"t-entry-visual-cont\"><div class=\"dummy\" style=\"padding-top: 133.3%;\"><\/div><a  class=\"inactive-link pushed\" data-lb-index=\"0\"><div class=\"t-entry-visual-overlay\"><div class=\"t-entry-visual-overlay-in style-dark-bg\" style=\"opacity: 0.5;\"><\/div><\/div><img decoding=\"async\" class=\"wp-image-118570\" src=\"https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA082025-120-uai-1024x1365.jpg\" width=\"1024\" height=\"1365\" alt=\"\" srcset=\"https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA082025-120-uai-1024x1365.jpg 1024w, https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA082025-120-8x12.jpg 8w, https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA082025-120-uai-720x960.jpg 720w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><\/div><\/div><div class=\"tmb tmb-no-double-tap tmb-grid tmb-iso-h4 tmb-light tmb-overlay-text-anim tmb-overlay-middle tmb-overlay-text-left tmb-id-118573  tmb-img-ratio tmb-media-first tmb-media-last tmb-content-overlay tmb-no-bg\" ><div class=\"t-inside no-anim\" ><div class=\"t-entry-visual\"><div class=\"t-entry-visual-tc\"><div class=\"t-entry-visual-cont\"><div class=\"dummy\" style=\"padding-top: 133.3%;\"><\/div><a  class=\"inactive-link pushed\" data-lb-index=\"1\"><div class=\"t-entry-visual-overlay\"><div class=\"t-entry-visual-overlay-in style-dark-bg\" style=\"opacity: 0.5;\"><\/div><\/div><img decoding=\"async\" class=\"wp-image-118573\" src=\"https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA-43-1-scaled-uai-1365x1820.jpg\" width=\"1365\" height=\"1820\" alt=\"\" srcset=\"https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA-43-1-scaled-uai-1365x1820.jpg 1365w, https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA-43-1-8x12.jpg 8w, https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA-43-1-scaled-uai-720x960.jpg 720w, https:\/\/doktershuisantverpia.com\/wp-content\/uploads\/2025\/10\/DOKTERSHUISANTVERPIA-43-1-scaled-uai-1032x1376.jpg 1032w\" sizes=\"(max-width: 1365px) 100vw, 1365px\" \/><\/a><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><\/div><\/div>\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n\t\n\t\n<\/div>\n\n<\/div><\/div><\/div><\/div><\/div><div class=\"wpb_column pos-top pos-left align_left column_child col-lg-6 kolom_contact_form kolom_colosopie_form one-internal-gutter\"><div class=\"uncol style-light shift_x_neg_single\" ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" style=\" max-width:85%;\" ><div class=\"empty-space empty-half\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\"  id=\"mobiel_responsief1\"><p class=\"font-146656 fontsize-501377 font-weight-500 text-color-227611-color\" ><span>Please use this form to schedule an appointment for an endoscopy. By completing the questions below, we can prepare the examination carefully and safely.<\/span><\/p><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"uncode_text_column\" ><div class=\"forminator-ui forminator-custom-form forminator-custom-form-118646 forminator-design--basic  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-118646\" data-uid=\"6a3e1d05ca114\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-118646\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-118646 forminator-design--basic  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"118646\"\r\n\t\t\t\t\r\n\t\t\t\tdata-design=\"basic\"\r\n\t\t\t\tdata-color-option=\"theme\"\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\tdata-grid=\"open\"\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\tstyle=\"display: none;\"\r\n\t\t\t\t\r\n\t\t\t\tdata-uid=\"6a3e1d05ca114\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1. General data<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a3e1d05ca114\" id=\"forminator-field-name-1_6a3e1d05ca114-label\" class=\"forminator-label\">First name and surname <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"First name and surname *\" id=\"forminator-field-name-1_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_6a3e1d05ca114\" id=\"forminator-field-text-13_6a3e1d05ca114-label\" class=\"forminator-label\">Date of birth <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"Date of birth *\" id=\"forminator-field-text-13_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a3e1d05ca114\" id=\"forminator-field-text-1_6a3e1d05ca114-label\" class=\"forminator-label\">National registry number<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"National registry number\" id=\"forminator-field-text-1_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a3e1d05ca114\" id=\"forminator-field-phone-1_6a3e1d05ca114-label\" class=\"forminator-label\">Phone number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Phone number *\" id=\"forminator-field-phone-1_6a3e1d05ca114\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a3e1d05ca114\" id=\"forminator-field-email-1_6a3e1d05ca114-label\" class=\"forminator-label\">Email address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"Email address *\" id=\"forminator-field-email-1_6a3e1d05ca114\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a3e1d05ca114\" id=\"forminator-field-text-2_6a3e1d05ca114-label\" class=\"forminator-label\">GP<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"GP\" id=\"forminator-field-text-2_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-2_6a3e1d05ca114-description\" \/><span id=\"forminator-field-text-2_6a3e1d05ca114-description\" class=\"forminator-description\">name + practice<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a3e1d05ca114\" id=\"forminator-field-text-3_6a3e1d05ca114-label\" class=\"forminator-label\">Referring specialist<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"Referring specialist (if applicable)\" id=\"forminator-field-text-3_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">2. Desired research<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12  form_vertical\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-1-6a3e1d05ca114-label\" class=\"forminator-label\">What research has been requested? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Gastroscopy (stomach examination)\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Gastroscopy (stomach examination)<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Coloscopy (bowel examination)\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Coloscopy (bowel examination)<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Combined gastroscopy &amp; colonoscopy\"><input type=\"radio\" name=\"radio-1\" value=\"Combinatie-gastroscopie-&amp;-coloscopie\" id=\"forminator-field-radio-1-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Combined gastroscopy &amp; colonoscopy<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12  form_vertical inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-2-6a3e1d05ca114-label\" class=\"forminator-label\">Was this examination requested by a doctor? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a3e1d05ca114\" id=\"forminator-field-text-4_6a3e1d05ca114-label\" class=\"forminator-label\">Reason for investigation \/ complaints <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"Reason for investigation \/ complaints\" id=\"forminator-field-text-4_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">3. Complaints and medical indication<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12  form_vertical\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a3e1d05ca114-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a3e1d05ca114-label\" class=\"forminator-label\">Do you currently have one or more of the following complaints?<\/span><label id=\"forminator-field-checkbox-2-1-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-1-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Abdominal pain\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-1-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abdominal pain<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-2-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Heartburn \/ reflux\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-2-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heartburn \/ reflux<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-3-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Nausea or vomiting\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Misselijkheid-of-braken\" id=\"forminator-field-checkbox-2-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-3-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nausea or vomiting<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-4-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Swallowing complaints\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Slikklachten\" id=\"forminator-field-checkbox-2-4-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-4-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Swallowing complaints<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-5-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Blood in stools\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Bloed-bij-de-ontlasting\" id=\"forminator-field-checkbox-2-5-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-5-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Blood in stools<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-6-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Black stools\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Zwarte-ontlasting\" id=\"forminator-field-checkbox-2-6-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-6-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Black stools<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-7-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Change in stools\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Verandering-in-ontlasting\" id=\"forminator-field-checkbox-2-7-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-7-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Change in stools<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-8-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Unexplained weight loss\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Onverklaard-gewichtsverlies\" id=\"forminator-field-checkbox-2-8-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-8-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Unexplained weight loss<\/span><\/label><label id=\"forminator-field-checkbox-2-9-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-9-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Anaemia\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Bloedarmoede\" id=\"forminator-field-checkbox-2-9-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-9-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anaemia<\/span><\/label><label id=\"forminator-field-checkbox-2-10-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-10-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Diarrhoea\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Diarree\" id=\"forminator-field-checkbox-2-10-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-10-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diarrhoea<\/span><\/label><label id=\"forminator-field-checkbox-2-11-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-11-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Obstipation\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Obstipatie\" id=\"forminator-field-checkbox-2-11-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-11-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Obstipation<\/span><\/label><label id=\"forminator-field-checkbox-2-12-6a3e1d05ca114-label\" for=\"forminator-field-checkbox-2-12-6a3e1d05ca114\" class=\"forminator-checkbox\" title=\"Other, namely:\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Anders,-namelijk\" id=\"forminator-field-checkbox-2-12-6a3e1d05ca114\" aria-labelledby=\"forminator-field-checkbox-2-12-6a3e1d05ca114-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-6a3e1d05ca114-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other, namely:<\/span><\/label><span id=\"forminator-field-checkbox-2-6a3e1d05ca114-description\" class=\"forminator-description\">Multiple answers possible<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a3e1d05ca114\" id=\"forminator-field-text-7_6a3e1d05ca114-label\" class=\"forminator-label\">Other complaint<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"Other complaint\" id=\"forminator-field-text-7_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">4. Previous studies<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12  form_vertical\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-3-6a3e1d05ca114-label\" class=\"forminator-label\">Have you had an endoscopy before? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, gastroscopy\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, gastroscopy<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, colonoscopy\"><input type=\"radio\" name=\"radio-3\" value=\"Ja,-coloscopie\" id=\"forminator-field-radio-3-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, colonoscopy<\/span><\/label><label id=\"forminator-field-radio-3-label-4\" for=\"forminator-field-radio-3-4-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, gastro- and colonoscopy\"><input type=\"radio\" name=\"radio-3\" value=\"Ja,-gastro--en-coloscopie\" id=\"forminator-field-radio-3-4-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-3-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, gastro- and colonoscopy<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a3e1d05ca114\" id=\"forminator-field-text-5_6a3e1d05ca114-label\" class=\"forminator-label\">If so, when and where?<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"If so, when and where?\" id=\"forminator-field-text-5_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a3e1d05ca114\" id=\"forminator-field-text-6_6a3e1d05ca114-label\" class=\"forminator-label\">Were there any peculiarities or complications?<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"Were there any peculiarities or complications?\" id=\"forminator-field-text-6_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">5. Medication<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-4-6a3e1d05ca114-label\" class=\"forminator-label\">Are you currently taking medication? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, namely:\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, namely:<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide namelijk_veld\"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a3e1d05ca114\" id=\"forminator-field-text-8_6a3e1d05ca114-label\" class=\"forminator-label\">Medications:<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"Medications:\" id=\"forminator-field-text-8_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-5-6a3e1d05ca114-label\" class=\"forminator-label\">Do you use blood thinners? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, namely:\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, namely:<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide namelijk_veld\"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a3e1d05ca114\" id=\"forminator-field-text-9_6a3e1d05ca114-label\" class=\"forminator-label\">Blood thinners:<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"Blood thinners:\" id=\"forminator-field-text-9_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-6-6a3e1d05ca114-label\" class=\"forminator-label\">Are you taking diabetes medication or insulin? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12  inline_form_radio\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">6. Allergies and hypersensitivities<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-7-6a3e1d05ca114-label\" class=\"forminator-label\">Do you have any allergies or hypersensitivities? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, namely:\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, namely:<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide namelijk_veld\"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_6a3e1d05ca114\" id=\"forminator-field-text-10_6a3e1d05ca114-label\" class=\"forminator-label\">Allergies or hypersensitivities:<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"Allergies or hypersensitivities:\" id=\"forminator-field-text-10_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-14\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-14-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-14-6a3e1d05ca114-label\" class=\"forminator-label\">Allergy to medication or anaesthesia\/sedation? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-14-label-1\" for=\"forminator-field-radio-14-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-14\" value=\"one\" id=\"forminator-field-radio-14-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-14-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-14-label-2\" for=\"forminator-field-radio-14-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-14\" value=\"two\" id=\"forminator-field-radio-14-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-14-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">7. Sedation (intoxication)<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-8-6a3e1d05ca114-label\" class=\"forminator-label\">Would you like the examination to be performed with sedation? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-8-label-3\" for=\"forminator-field-radio-8-3-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Don&#039;t know yet\"><input type=\"radio\" name=\"radio-8\" value=\"Weet-ik-nog-niet\" id=\"forminator-field-radio-8-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-8-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Don't know yet<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-9-6a3e1d05ca114-label\" class=\"forminator-label\">Have you been sedated before? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, without any problems\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, without any problems<\/span><\/label><label id=\"forminator-field-radio-9-label-3\" for=\"forminator-field-radio-9-3-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes, with problems (explanation)\"><input type=\"radio\" name=\"radio-9\" value=\"Ja,-met-problemen-(toelichting)\" id=\"forminator-field-radio-9-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-9-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes, with problems (explanation)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_6a3e1d05ca114\" id=\"forminator-field-text-11_6a3e1d05ca114-label\" class=\"forminator-label\">Notes:<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"Notes:\" id=\"forminator-field-text-11_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">8. Medical background<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-10-6a3e1d05ca114-label\" class=\"forminator-label\">Do you have any of the following conditions? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Heart disease\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Heart disease<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Lung disease (asthma\/COPD)\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Lung disease (asthma\/COPD)<\/span><\/label><label id=\"forminator-field-radio-10-label-3\" for=\"forminator-field-radio-10-3-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Neurological disorder\"><input type=\"radio\" name=\"radio-10\" value=\"Neurologische-aandoening\" id=\"forminator-field-radio-10-3-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Neurological disorder<\/span><\/label><label id=\"forminator-field-radio-10-label-4\" for=\"forminator-field-radio-10-4-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Sleep apnoea\"><input type=\"radio\" name=\"radio-10\" value=\"Slaapapneu\" id=\"forminator-field-radio-10-4-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Sleep apnoea<\/span><\/label><label id=\"forminator-field-radio-10-label-5\" for=\"forminator-field-radio-10-5-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Kidney disease\"><input type=\"radio\" name=\"radio-10\" value=\"Nierziekte\" id=\"forminator-field-radio-10-5-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Kidney disease<\/span><\/label><label id=\"forminator-field-radio-10-label-6\" for=\"forminator-field-radio-10-6-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Liver disease\"><input type=\"radio\" name=\"radio-10\" value=\"Leverziekte\" id=\"forminator-field-radio-10-6-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Liver disease<\/span><\/label><label id=\"forminator-field-radio-10-label-7\" for=\"forminator-field-radio-10-7-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Coagulation disorder\"><input type=\"radio\" name=\"radio-10\" value=\"Stollingsstoornis\" id=\"forminator-field-radio-10-7-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-7\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Coagulation disorder<\/span><\/label><label id=\"forminator-field-radio-10-label-8\" for=\"forminator-field-radio-10-8-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Pregnancy\"><input type=\"radio\" name=\"radio-10\" value=\"Zwangerschap\" id=\"forminator-field-radio-10-8-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-8\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Pregnancy<\/span><\/label><label id=\"forminator-field-radio-10-label-9\" for=\"forminator-field-radio-10-9-6a3e1d05ca114\" class=\"forminator-radio\" title=\"None of the above\"><input type=\"radio\" name=\"radio-10\" value=\"Geen-van-bovenstaande\" id=\"forminator-field-radio-10-9-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-10-label-9\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None of the above<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_6a3e1d05ca114\" id=\"forminator-field-text-12_6a3e1d05ca114-label\" class=\"forminator-label\">Under treatment by a specialist?<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"Are you under treatment by a specialist? If yes, which one?\" id=\"forminator-field-text-12_6a3e1d05ca114\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-9\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">9. Practical matters<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-11-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-11-6a3e1d05ca114-label\" class=\"forminator-label\">Are you mobile independent? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-12  inline_form_radio\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-12-6a3e1d05ca114-label\"><span id=\"forminator-radiogroup-radio-12-6a3e1d05ca114-label\" class=\"forminator-label\">Are you a member of the Belgian Mutual Health Service? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-6a3e1d05ca114\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-12\" value=\"one\" id=\"forminator-field-radio-12-1-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-6a3e1d05ca114\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-12\" value=\"two\" id=\"forminator-field-radio-12-2-6a3e1d05ca114\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-10\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">10. Consent &amp; agreement<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12  label_hide\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_6a3e1d05ca114\" id=\"forminator-field-consent-1_6a3e1d05ca114-label\" class=\"forminator-label\">Consent &amp; agreement <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6a3e1d05ca114__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-1_6a3e1d05ca114-label\" aria-hidden=\"true\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a3e1d05ca114\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a3e1d05ca114-label\" aria-describedby=\"forminator-field-consent-1_6a3e1d05ca114__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a3e1d05ca114__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>Important information and agreement: An endoscopy (gastroscopy, colonoscopy or combination examination) requires specific preparation.<br>This preparation is essential to perform the examination safely and reliably. After making the appointment, you will receive detailed instructions by e-mail. Without proper preparation, the examination cannot take place and the appointment must be rescheduled. This may lead to unnecessary waiting time and additional costs.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-2\" class=\"forminator-field-consent forminator-col forminator-col-12  label_hide akkoord2_field\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-2_6a3e1d05ca114\" id=\"forminator-field-consent-2_6a3e1d05ca114-label\" class=\"forminator-label\">Accord 2 <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-2_6a3e1d05ca114__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-2_6a3e1d05ca114-label\" aria-hidden=\"true\"><input type=\"checkbox\" name=\"consent-2\" id=\"forminator-field-consent-2_6a3e1d05ca114\" value=\"checked\" aria-labelledby=\"forminator-field-consent-2_6a3e1d05ca114-label\" aria-describedby=\"forminator-field-consent-2_6a3e1d05ca114__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-2_6a3e1d05ca114__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>I certify that the above information has been entered truthfully.<\/p><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Making an appointment<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"e9b9d7fab1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/118642\" \/><input type=\"hidden\" name=\"form_id\" value=\"118646\"><input type=\"hidden\" name=\"page_id\" value=\"118642\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/doktershuisantverpia.com\/en\/coloscopy-gastroscopy-appointment\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-1\" data-row=\"script-row-unique-1\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-1\"));<\/script><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"AFSPRAAK endoscopie Met behulp van dit formulier plant u een afspraak voor een endoscopie. Door onderstaande vragen in te vullen, [...]","protected":false},"author":17,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"wds_primary_page_category":0,"footnotes":""},"class_list":["post-118642","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/pages\/118642","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/comments?post=118642"}],"version-history":[{"count":4,"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/pages\/118642\/revisions"}],"predecessor-version":[{"id":118974,"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/pages\/118642\/revisions\/118974"}],"wp:attachment":[{"href":"https:\/\/doktershuisantverpia.com\/en\/wp-json\/wp\/v2\/media?parent=118642"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}