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        <div id="cid_24" class="form-input-wide always-hidden" data-layout="half"> <input type="number" id="input_24" name="q24_patientIdentity" data-type="input-number" class=" form-number-input form-textbox" data-defaultvalue="" style="width:310px" size="310" placeholder="e.g., 23" data-component="number" aria-labelledby="label_24" step="any" value="" /> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_radio" id="id_18"><label class="form-label form-label-top form-label-auto" id="label_18" aria-hidden="false"> Gender </label>
        <div id="cid_18" class="form-input-wide always-hidden" data-layout="full">
          <div class="form-single-column" role="group" aria-labelledby="label_18" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_18" type="radio" class="form-radio" id="input_18_0" name="q18_gender" value="Male" /><label id="label_input_18_0" for="input_18_0">Male</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_18" type="radio" class="form-radio" id="input_18_1" name="q18_gender" value="Female" /><label id="label_input_18_1" for="input_18_1">Female</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_18" type="radio" class="form-radio" id="input_18_2" name="q18_gender" value="Other" /><label id="label_input_18_2" for="input_18_2">Other</label></span></div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-1 always-hidden jf-required" data-type="control_datetime" id="id_3"><label class="form-label form-label-top" id="label_3" for="lite_mode_3" aria-hidden="false"> Date of Birth<span class="form-required">*</span> </label>
        <div id="cid_3" class="form-input-wide always-hidden jf-required" data-layout="half">
          <div data-wrapper-react="true">
            <div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="month_3" name="q3_dateOf[month]" type="tel" size="2" data-maxlength="2" data-age="" maxLength="2" autoComplete="off" aria-labelledby="label_3 sublabel_3_month" value="" /><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="month_3" id="sublabel_3_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="day_3" name="q3_dateOf[day]" type="tel" size="2" data-maxlength="2" data-age="" maxLength="2" autoComplete="off" aria-labelledby="label_3 sublabel_3_day" value="" /><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_3" id="sublabel_3_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="year_3" name="q3_dateOf[year]" type="tel" size="4" data-maxlength="4" data-age="" maxLength="4" autoComplete="off" aria-labelledby="label_3 sublabel_3_year" value="" /><label class="form-sub-label" for="year_3" id="sublabel_3_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_3" type="text" size="12" data-maxlength="12" maxLength="12" data-age="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_3 sublabel_3_litemode" value="" /><button type="button" class=" newDefaultTheme-dateIcon focusable icon-liteMode" id="input_3_pick" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2"></button><label class="form-sub-label" for="lite_mode_3" id="sublabel_3_litemode" style="min-height:13px">Date</label></span>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-2 always-hidden" data-type="control_number" id="id_16"><label class="form-label form-label-top" id="label_16" for="input_16" aria-hidden="false"> Patient Age </label>
        <div id="cid_16" class="form-input-wide always-hidden" data-layout="half"> <input type="number" id="input_16" name="q16_patientAge" data-type="input-number" class=" form-number-input form-textbox" data-defaultvalue="" style="width:310px" size="310" placeholder="e.g., 23" data-component="number" aria-labelledby="label_16" step="any" value="" /> </div>
      </li>
      <li class="form-line form-line-column form-col-3 always-hidden" data-type="control_dropdown" id="id_20"><label class="form-label form-label-top" id="label_20" for="input_20" aria-hidden="false"> Mode of Payment </label>
        <div id="cid_20" class="form-input-wide always-hidden" data-layout="half"> <select class="form-dropdown" id="input_20" name="q20_modeOf" style="width:310px" data-component="dropdown" aria-label="Mode of Payment ">
            <option value="">Please Select</option>
            <option value="Cash Payment">Cash Payment</option>
            <option value="Medical Aid Payment">Medical Aid Payment</option>
            <option value="LOYALAID PAY">LOYALAID PAY</option>
          </select> </div>
      </li>
      <li class="form-line form-line-column form-col-4 always-hidden" data-type="control_dropdown" id="id_21"><label class="form-label form-label-top" id="label_21" for="input_21" aria-hidden="false"> Select Your Medical Aid </label>
        <div id="cid_21" class="form-input-wide always-hidden" data-layout="half"> <select class="form-dropdown" id="input_21" name="q21_selectYour" style="width:310px" data-component="dropdown" aria-label="Select Your Medical Aid">
            <option value="">Please Select</option>
            <option value="LOYALAID DIGITAL PAY">LOYALAID DIGITAL PAY</option>
            <option value="METROPOLITAN MEDICAL AID">METROPOLITAN MEDICAL AID</option>
            <option value="LIBERTY MEDICAL AID">LIBERTY MEDICAL AID</option>
            <option value="DISCOVERY MEDICAL AID">DISCOVERY MEDICAL AID</option>
            <option value="VITALITY MEDICAL AID">VITALITY MEDICAL AID</option>
            <option value="MOMENTUM">MOMENTUM</option>
            <option value="FEDHEALTH MEDICAL AID">FEDHEALTH MEDICAL AID</option>
            <option value="GEMS MEDICAL AID">GEMS MEDICAL AID</option>
            <option value="MEDSHIELD MEDICAL AID">MEDSHIELD MEDICAL AID</option>
            <option value="BANKMED MEDICAL AID">BANKMED MEDICAL AID</option>
            <option value="BONITAS MEDICAL AID BON0979511">BONITAS MEDICAL AID BON0979511</option>
            <option value="ENGEN MEDICAL AID">ENGEN MEDICAL AID</option>
            <option value=""></option>
          </select> </div>
      </li>
      <li class="form-line form-line-column form-col-5 always-hidden" data-type="control_radio" id="id_22"><label class="form-label form-label-top" id="label_22" aria-hidden="false"> Membership Status </label>
        <div id="cid_22" class="form-input-wide always-hidden" data-layout="full">
          <div class="form-single-column" role="group" aria-labelledby="label_22" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="radio" class="form-radio" id="input_22_0" name="q22_membershipStatus" value="Main Member" /><label id="label_input_22_0" for="input_22_0">Main Member</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="radio" class="form-radio" id="input_22_1" name="q22_membershipStatus" value="Dependant" /><label id="label_input_22_1" for="input_22_1">Dependant</label></span></div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-6 always-hidden" data-type="control_number" id="id_23"><label class="form-label form-label-top" id="label_23" for="input_23" aria-hidden="false"> Medical Aid Number </label>
        <div id="cid_23" class="form-input-wide always-hidden" data-layout="half"> <input type="number" id="input_23" name="q23_medicalAid" data-type="input-number" class=" form-number-input form-textbox" data-defaultvalue="" style="width:310px" size="310" placeholder="e.g., 23" data-component="number" aria-labelledby="label_23" step="any" value="" /> </div>
      </li>
      <li class="form-line form-line-column form-col-7" data-type="control_inline" id="id_13">
        <div id="cid_13" class="form-input-wide" data-layout="full">
          <div id="FITB_13" class="FITB formRender">
            <p>Blood Pressure <span data-type="textbox" data-grouptype="control_textbox" class="FITB-inptCont" data-blot-id="shorttext-1"><input class="form-textbox " name="q13_input13[shorttext-1]" id="13_shorttext-1" type="text" /><label for="13_shorttext-1">blanks </label></span> mmHg<br />Pulse Rate <span data-type="textbox" data-grouptype="control_textbox" class="FITB-inptCont" data-blot-id="shorttext-2"><input class="form-textbox " name="q13_input13[shorttext-2]" id="13_shorttext-2" type="text" /><label for="13_shorttext-2">blank </label></span> bpm<br />RBS   <span data-type="textbox" data-grouptype="control_number" class="FITB-inptCont" data-blot-id="number-4"><input class="form-textbox form-number-input validate[]" name="q13_input13[number-4]" id="13_number-4" type="number" /><label for="13_number-4"></label></span>   %</p>
          </div>
        </div>
      </li>
      <li class="form-line form-line-column form-col-8" data-type="control_inline" id="id_25">
        <div id="cid_25" class="form-input-wide" data-layout="full">
          <div id="FITB_25" class="FITB formRender">
            <p>Resp Patten   <span data-type="textbox" data-grouptype="control_textbox" class="FITB-inptCont" data-blot-id="shorttext-4"><input class="form-textbox  validate[]" name="q25_input25[shorttext-4]" id="25_shorttext-4" type="text" /><label for="25_shorttext-4">Type a label</label></span>   <br />Spo2<span data-type="textbox" data-grouptype="control_number" class="FITB-inptCont" data-blot-id="number-3"><input class="form-textbox form-number-input validate[]" name="q25_input25[number-3]" id="25_number-3" type="number" /><label for="25_number-3">Blank</label></span>   %<br />Temp   <span data-type="textbox" data-grouptype="control_number" class="FITB-inptCont" data-blot-id="number-5"><input class="form-textbox form-number-input validate[]" name="q25_input25[number-5]" id="25_number-5" type="number" /><label for="25_number-5"></label></span>   Celcius</p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textarea" id="id_12"><label class="form-label form-label-top form-label-auto" id="label_12" for="input_12" aria-hidden="false"> Diagnosis </label>
        <div id="cid_12" class="form-input-wide" data-layout="full"> <textarea id="input_12" class="form-textarea" name="q12_diagnosis" style="width:648px;height:64px" data-component="textarea" aria-labelledby="label_12"></textarea> </div>
      </li>
      <li class="form-line" data-type="control_matrix" id="id_11"><label class="form-label form-label-top form-label-auto" id="label_11" for="input_11" aria-hidden="false"> Prescription </label>
        <div id="cid_11" class="form-input-wide" data-layout="full">
          <table summary="" role="table" aria-labelledby="label_11" cellPadding="4" cellSpacing="0" class="form-matrix-table" data-component="matrix" data-dynamic="true">
            <tr class="form-matrix-tr form-matrix-header-tr">
              <th class="form-matrix-th" style="border:none"> </th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_0"><label id="label_11_col_0">Prescription Items Rx</label></th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_1"><label id="label_11_col_1">Rx Quantity</label></th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_2"><label id="label_11_col_2">Rx Frequency (OD/BD/TDS)</label></th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_3"><label id="label_11_col_3">Rx Instruction </label></th>
              <th scope="col" class="form-matrix-headers form-matrix-column-headers form-matrix-column_4"><label id="label_11_col_4">Rx Duration</label></th>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_0">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_0">1</label></th>
              <td class="form-matrix-values"><input id="input_11_0_0" class="form-textbox" type="text" size="5" name="q11_prescription[0][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_0" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_0_1" class="form-dropdown" name="q11_prescription[0][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_0" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_0_2" class="form-dropdown" name="q11_prescription[0][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_0" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_0_3" class="form-dropdown" name="q11_prescription[0][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_0" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_0_4" class="form-dropdown" name="q11_prescription[0][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_0" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_1">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_1">2</label></th>
              <td class="form-matrix-values"><input id="input_11_1_0" class="form-textbox" type="text" size="5" name="q11_prescription[1][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_1" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_1_1" class="form-dropdown" name="q11_prescription[1][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_1" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_1_2" class="form-dropdown" name="q11_prescription[1][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_1" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_1_3" class="form-dropdown" name="q11_prescription[1][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_1" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_1_4" class="form-dropdown" name="q11_prescription[1][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_1" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_2">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_2">3</label></th>
              <td class="form-matrix-values"><input id="input_11_2_0" class="form-textbox" type="text" size="5" name="q11_prescription[2][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_2" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_2_1" class="form-dropdown" name="q11_prescription[2][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_2" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_2_2" class="form-dropdown" name="q11_prescription[2][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_2" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_2_3" class="form-dropdown" name="q11_prescription[2][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_2" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_2_4" class="form-dropdown" name="q11_prescription[2][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_2" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_3">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_3">4</label></th>
              <td class="form-matrix-values"><input id="input_11_3_0" class="form-textbox" type="text" size="5" name="q11_prescription[3][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_3" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_3_1" class="form-dropdown" name="q11_prescription[3][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_3" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_3_2" class="form-dropdown" name="q11_prescription[3][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_3" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_3_3" class="form-dropdown" name="q11_prescription[3][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_3" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_3_4" class="form-dropdown" name="q11_prescription[3][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_3" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_4">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_4">5</label></th>
              <td class="form-matrix-values"><input id="input_11_4_0" class="form-textbox" type="text" size="5" name="q11_prescription[4][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_4" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_4_1" class="form-dropdown" name="q11_prescription[4][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_4" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_4_2" class="form-dropdown" name="q11_prescription[4][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_4" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_4_3" class="form-dropdown" name="q11_prescription[4][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_4" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_4_4" class="form-dropdown" name="q11_prescription[4][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_4" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_5">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_5">6</label></th>
              <td class="form-matrix-values"><input id="input_11_5_0" class="form-textbox" type="text" size="5" name="q11_prescription[5][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_5" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_5_1" class="form-dropdown" name="q11_prescription[5][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_5" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_5_2" class="form-dropdown" name="q11_prescription[5][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_5" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_5_3" class="form-dropdown" name="q11_prescription[5][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_5" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_5_4" class="form-dropdown" name="q11_prescription[5][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_5" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
            </tr>
            <tr class="form-matrix-tr form-matrix-value-tr" aria-labelledby="label_11 label_11_row_6">
              <th scope="row" class="form-matrix-headers form-matrix-row-headers"><label id="label_11_row_6">7</label></th>
              <td class="form-matrix-values"><input id="input_11_6_0" class="form-textbox" type="text" size="5" name="q11_prescription[6][0]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_0 label_11_row_6" aria-label="Cells Text Box" value="" /></td>
              <td class="form-matrix-values"><select id="input_11_6_1" class="form-dropdown" name="q11_prescription[6][1]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_1 label_11_row_6" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="5ml Teaspoon">5ml Teaspoon</option>
                  <option value="10ml ">10ml </option>
                  <option value="15ml ">15ml </option>
                  <option value="20ml ">20ml </option>
                  <option value="1 Tablet">1 Tablet</option>
                  <option value="2 Tablets">2 Tablets</option>
                  <option value="3Tablets">3Tablets</option>
                  <option value="4 Tablets">4 Tablets</option>
                  <option value="5 Tablets">5 Tablets</option>
                  <option value="6 Tablets">6 Tablets</option>
                  <option value="7 Tablets">7 Tablets</option>
                  <option value="8 Tablets">8 Tablets</option>
                  <option value="9 Tablets">9 Tablets</option>
                  <option value="10 Tablets">10 Tablets</option>
                  <option value="11 Tablets">11 Tablets</option>
                  <option value="12 Tablets">12 Tablets</option>
                  <option value="13 Tablets">13 Tablets</option>
                  <option value="14 Tablets">14 Tablets</option>
                  <option value="15 Tablets">15 Tablets</option>
                  <option value="16 Tablets">16 Tablets</option>
                  <option value="17 Tablets">17 Tablets</option>
                  <option value="18 Tablets">18 Tablets</option>
                  <option value="19 Tablets">19 Tablets</option>
                  <option value="20 Tablets">20 Tablets</option>
                  <option value="21 Tablets">21 Tablets</option>
                  <option value="22 Tablets">22 Tablets</option>
                  <option value="23 Tablets">23 Tablets</option>
                  <option value="24 Tablets">24 Tablets</option>
                  <option value="25 Tablets">25 Tablets</option>
                  <option value="26 Tablets">26 Tablets</option>
                  <option value="27 Tablets">27 Tablets</option>
                  <option value="28 Tablets">28 Tablets</option>
                  <option value="29 Tablets">29 Tablets</option>
                  <option value="30 Tablets">30 Tablets</option>
                  <option value="31 Tablets">31 Tablets</option>
                  <option value="32 Tablets">32 Tablets</option>
                  <option value="33 Tablets">33 Tablets</option>
                  <option value="34 Tablets">34 Tablets</option>
                  <option value="35 Tablets">35 Tablets</option>
                  <option value="36 Tablets">36 Tablets</option>
                  <option value="37 Tablets">37 Tablets</option>
                  <option value="38 Tablets">38 Tablets</option>
                  <option value="39 Tablets">39 Tablets</option>
                  <option value="40 Tablets">40 Tablets</option>
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              <td class="form-matrix-values"><select id="input_11_6_2" class="form-dropdown" name="q11_prescription[6][2]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_2 label_11_row_6" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="Once a day">Once a day</option>
                  <option value="Immediately">Immediately</option>
                  <option value="At night">At night</option>
                  <option value="At bedtime">At bedtime</option>
                  <option value="Twice a day">Twice a day</option>
                  <option value="Three times a day">Three times a day</option>
                  <option value="Four times a day">Four times a day</option>
                  <option value="Every four hours">Every four hours</option>
                  <option value="Every six hours">Every six hours</option>
                  <option value="Every eight hours">Every eight hours</option>
                  <option value="Every twelve hours">Every twelve hours</option>
                  <option value="Every twenty-four hours">Every twenty-four hours</option>
                  <option value="Once a week">Once a week</option>
                  <option value="Every week">Every week</option>
                  <option value="Once a month">Once a month</option>
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              <td class="form-matrix-values"><select id="input_11_6_3" class="form-dropdown" name="q11_prescription[6][3]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_3 label_11_row_6" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="When required">When required</option>
                  <option value="Finish the Course">Finish the Course</option>
                  <option value="Only if necessary">Only if necessary</option>
                  <option value="Before meals">Before meals</option>
                  <option value="After meals">After meals</option>
                  <option value="With food">With food</option>
                  <option value="On alternate days">On alternate days</option>
                  <option value="At night only">At night only</option>
                  <option value="As directed by your healthcare provider">As directed by your healthcare provider</option>
                  <option value="Up to the maximum prescribed dose">Up to the maximum prescribed dose</option>
                  <option value="Gradually increase or decrease the dose as instructed">Gradually increase or decrease the dose as instructed</option>
                </select></td>
              <td class="form-matrix-values"><select id="input_11_6_4" class="form-dropdown" name="q11_prescription[6][4]" style="width:100%;box-sizing:border-box" aria-labelledby="label_11_col_4 label_11_row_6" aria-label="Cells Select Box">
                  <option aria-label="Please select"></option>
                  <option value="1  Day Treatment">1 Day Treatment</option>
                  <option value="2 Days Treatment">2 Days Treatment</option>
                  <option value="3 Days Treatment">3 Days Treatment</option>
                  <option value="4 Days Treatment">4 Days Treatment</option>
                  <option value="5 Days Treatment">5 Days Treatment</option>
                  <option value="6 Days Treatment">6 Days Treatment</option>
                  <option value="7 Days Treatment">7 Days Treatment</option>
                  <option value="1 Week Treatment">1 Week Treatment</option>
                  <option value="2 Weeks Treatment">2 Weeks Treatment</option>
                  <option value="3 Weeks Treatment">3 Weeks Treatment</option>
                  <option value="4 Weeks Treatment">4 Weeks Treatment</option>
                  <option value="5 Weeks Treatment">5 Weeks Treatment</option>
                  <option value="1 Month  Treatment">1 Month Treatment</option>
                  <option value="2 Months  Treatment">2 Months Treatment</option>
                  <option value="3 Months Treatment">3 Months Treatment</option>
                  <option value="4 Months  Treatment">4 Months Treatment</option>
                  <option value="5 Months  Treatment">5 Months Treatment</option>
                  <option value="6 Months  Treatment">6 Months Treatment</option>
                  <option value="12 Months Treatment">12 Months Treatment</option>
                </select></td>
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      <li class="form-line jf-required" data-type="control_textarea" id="id_6"><label class="form-label form-label-top form-label-auto" id="label_6" for="input_6" aria-hidden="false"> Additional Prescription Details<span class="form-required">*</span> </label>
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                  <div class="jfUpload-button-container">
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                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_8" name="q8_uploadPrescription[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="pdf, doc, docx, xls, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif" data-limit-file-size="Yes" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="0" data-component="fileupload" aria-label="Upload a File" /></div>
                </div>
              </div>
              <div data-wrapper-react="true"></div>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_button" id="id_10">
        <div id="cid_10" class="form-input-wide" data-layout="full">
          <div data-align="auto" class="form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField"><button id="input_10" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="">Generate Prescription</button></div>
        </div>
      </li>
      <li style="clear:both"></li>
      <li style="display:none">Should be Empty: <input type="text" name="website" value="" type="hidden" /></li>
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