someone created a form for me and I want to copy it and edit the details

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    jherongarrett
    Asked on March 17, 2014 at 09:00 AM

    <form class="jotform-form" action="http://submit.jotform.me/submit/31345264095453/" method="post" name="form_31345264095453" id="31345264095453" accept-charset="utf-8" novalidate="true">

      <input type="hidden" name="formID" value="31345264095453">

      <div class="form-all">

        <ul class="form-section">

          <li id="cid_1" class="form-input-wide">

            <div class="form-header-group">

              <h1 id="header_1" class="form-header">

                MEDICAL/SURGICAL HISTORY FORM

              </h1>

            </div>

          </li>

          <li id="cid_160" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_160" class="form-header">

                Personal Information:

              </h2>

            </div>

          </li>

          <li class="form-line" id="id_161">

            <label class="form-label-top" id="label_161" for="input_161"> Name: </label>

            <div id="cid_161" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_161" name="q161_name" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_162">

            <label class="form-label-top" id="label_162" for="input_162"> Address </label>

            <div id="cid_162" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_162" name="q162_address" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_164">

            <label class="form-label-top" id="label_164" for="input_164"> City </label>

            <div id="cid_164" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_164" name="q164_city" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_173">

            <label class="form-label-top" id="label_173" for="input_173"> State </label>

            <div id="cid_173" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_173" name="q173_state" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_165">

            <label class="form-label-top" id="label_165" for="input_165"> Zip </label>

            <div id="cid_165" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_165" name="q165_zip" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_174">

            <label class="form-label-top" id="label_174" for="input_174"> Country </label>

            <div id="cid_174" class="form-input-wide">

              <select class="form-dropdown" style="width:200px" id="input_174" name="q174_country">

                <option value="">  </option>

                <option value="United States"> United States </option>

                <option value="Afghanistan"> Afghanistan </option>

                <option value="Albania"> Albania </option>

                <option value="Algeria"> Algeria </option>

                <option value="American Samoa"> American Samoa </option>

                <option value="Andorra"> Andorra </option>

                <option value="Angola"> Angola </option>

                <option value="Anguilla"> Anguilla </option>

                <option value="Antigua and Barbuda"> Antigua and Barbuda </option>

                <option value="Argentina"> Argentina </option>

                <option value="Armenia"> Armenia </option>

                <option value="Aruba"> Aruba </option>

                <option value="Australia"> Australia </option>

                <option value="Austria"> Austria </option>

                <option value="Azerbaijan"> Azerbaijan </option>

                <option value="The Bahamas"> The Bahamas </option>

                <option value="Bahrain"> Bahrain </option>

                <option value="Bangladesh"> Bangladesh </option>

                <option value="Barbados"> Barbados </option>

                <option value="Belarus"> Belarus </option>

                <option value="Belgium"> Belgium </option>

                <option value="Belize"> Belize </option>

                <option value="Benin"> Benin </option>

                <option value="Bermuda"> Bermuda </option>

                <option value="Bhutan"> Bhutan </option>

                <option value="Bolivia"> Bolivia </option>

                <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>

                <option value="Botswana"> Botswana </option>

                <option value="Brazil"> Brazil </option>

                <option value="Brunei"> Brunei </option>

                <option value="Bulgaria"> Bulgaria </option>

                <option value="Burkina Faso"> Burkina Faso </option>

                <option value="Burundi"> Burundi </option>

                <option value="Cambodia"> Cambodia </option>

                <option value="Cameroon"> Cameroon </option>

                <option value="Canada"> Canada </option>

                <option value="Cape Verde"> Cape Verde </option>

                <option value="Cayman Islands"> Cayman Islands </option>

                <option value="Central African Republic"> Central African Republic </option>

                <option value="Chad"> Chad </option>

                <option value="Chile"> Chile </option>

                <option value="People's Republic of China"> People's Republic of China </option>

                <option value="Republic of China"> Republic of China </option>

                <option value="Christmas Island"> Christmas Island </option>

                <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>

                <option value="Colombia"> Colombia </option>

                <option value="Comoros"> Comoros </option>

                <option value="Congo"> Congo </option>

                <option value="Cook Islands"> Cook Islands </option>

                <option value="Costa Rica"> Costa Rica </option>

                <option value="Cote d'Ivoire"> Cote d'Ivoire </option>

                <option value="Croatia"> Croatia </option>

                <option value="Cuba"> Cuba </option>

                <option value="Cyprus"> Cyprus </option>

                <option value="Czech Republic"> Czech Republic </option>

                <option value="Denmark"> Denmark </option>

                <option value="Djibouti"> Djibouti </option>

                <option value="Dominica"> Dominica </option>

                <option value="Dominican Republic"> Dominican Republic </option>

                <option value="Ecuador"> Ecuador </option>

                <option value="Egypt"> Egypt </option>

                <option value="El Salvador"> El Salvador </option>

                <option value="Equatorial Guinea"> Equatorial Guinea </option>

                <option value="Eritrea"> Eritrea </option>

                <option value="Estonia"> Estonia </option>

                <option value="Ethiopia"> Ethiopia </option>

                <option value="Falkland Islands"> Falkland Islands </option>

                <option value="Faroe Islands"> Faroe Islands </option>

                <option value="Fiji"> Fiji </option>

                <option value="Finland"> Finland </option>

                <option value="France"> France </option>

                <option value="French Polynesia"> French Polynesia </option>

                <option value="Gabon"> Gabon </option>

                <option value="The Gambia"> The Gambia </option>

                <option value="Georgia"> Georgia </option>

                <option value="Germany"> Germany </option>

                <option value="Ghana"> Ghana </option>

                <option value="Gibraltar"> Gibraltar </option>

                <option value="Greece"> Greece </option>

                <option value="Greenland"> Greenland </option>

                <option value="Grenada"> Grenada </option>

                <option value="Guadeloupe"> Guadeloupe </option>

                <option value="Guam"> Guam </option>

                <option value="Guatemala"> Guatemala </option>

                <option value="Guernsey"> Guernsey </option>

                <option value="Guinea"> Guinea </option>

                <option value="Guinea-Bissau"> Guinea-Bissau </option>

                <option value="Guyana"> Guyana </option>

                <option value="Haiti"> Haiti </option>

                <option value="Honduras"> Honduras </option>

                <option value="Hong Kong"> Hong Kong </option>

                <option value="Hungary"> Hungary </option>

                <option value="Iceland"> Iceland </option>

                <option value="India"> India </option>

                <option value="Indonesia"> Indonesia </option>

                <option value="Iran"> Iran </option>

                <option value="Iraq"> Iraq </option>

                <option value="Ireland"> Ireland </option>

                <option value="Israel"> Israel </option>

                <option value="Italy"> Italy </option>

                <option value="Jamaica"> Jamaica </option>

                <option value="Japan"> Japan </option>

                <option value="Jersey"> Jersey </option>

                <option value="Jordan"> Jordan </option>

                <option value="Kazakhstan"> Kazakhstan </option>

                <option value="Kenya"> Kenya </option>

                <option value="Kiribati"> Kiribati </option>

                <option value="North Korea"> North Korea </option>

                <option value="South Korea"> South Korea </option>

                <option value="Kosovo"> Kosovo </option>

                <option value="Kuwait"> Kuwait </option>

                <option value="Kyrgyzstan"> Kyrgyzstan </option>

                <option value="Laos"> Laos </option>

                <option value="Latvia"> Latvia </option>

                <option value="Lebanon"> Lebanon </option>

                <option value="Lesotho"> Lesotho </option>

                <option value="Liberia"> Liberia </option>

                <option value="Libya"> Libya </option>

                <option value="Liechtenstein"> Liechtenstein </option>

                <option value="Lithuania"> Lithuania </option>

                <option value="Luxembourg"> Luxembourg </option>

                <option value="Macau"> Macau </option>

                <option value="Macedonia"> Macedonia </option>

                <option value="Madagascar"> Madagascar </option>

                <option value="Malawi"> Malawi </option>

                <option value="Malaysia"> Malaysia </option>

                <option value="Maldives"> Maldives </option>

                <option value="Mali"> Mali </option>

                <option value="Malta"> Malta </option>

                <option value="Marshall Islands"> Marshall Islands </option>

                <option value="Martinique"> Martinique </option>

                <option value="Mauritania"> Mauritania </option>

                <option value="Mauritius"> Mauritius </option>

                <option value="Mayotte"> Mayotte </option>

                <option value="Mexico"> Mexico </option>

                <option value="Micronesia"> Micronesia </option>

                <option value="Moldova"> Moldova </option>

                <option value="Monaco"> Monaco </option>

                <option value="Mongolia"> Mongolia </option>

                <option value="Montenegro"> Montenegro </option>

                <option value="Montserrat"> Montserrat </option>

                <option value="Morocco"> Morocco </option>

                <option value="Mozambique"> Mozambique </option>

                <option value="Myanmar"> Myanmar </option>

                <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>

                <option value="Namibia"> Namibia </option>

                <option value="Nauru"> Nauru </option>

                <option value="Nepal"> Nepal </option>

                <option value="Netherlands"> Netherlands </option>

                <option value="Netherlands Antilles"> Netherlands Antilles </option>

                <option value="New Caledonia"> New Caledonia </option>

                <option value="New Zealand"> New Zealand </option>

                <option value="Nicaragua"> Nicaragua </option>

                <option value="Niger"> Niger </option>

                <option value="Nigeria"> Nigeria </option>

                <option value="Niue"> Niue </option>

                <option value="Norfolk Island"> Norfolk Island </option>

                <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>

                <option value="Northern Mariana"> Northern Mariana </option>

                <option value="Norway"> Norway </option>

                <option value="Oman"> Oman </option>

                <option value="Pakistan"> Pakistan </option>

                <option value="Palau"> Palau </option>

                <option value="Palestine"> Palestine </option>

                <option value="Panama"> Panama </option>

                <option value="Papua New Guinea"> Papua New Guinea </option>

                <option value="Paraguay"> Paraguay </option>

                <option value="Peru"> Peru </option>

                <option value="Philippines"> Philippines </option>

                <option value="Pitcairn Islands"> Pitcairn Islands </option>

                <option value="Poland"> Poland </option>

                <option value="Portugal"> Portugal </option>

                <option value="Puerto Rico"> Puerto Rico </option>

                <option value="Qatar"> Qatar </option>

                <option value="Romania"> Romania </option>

                <option value="Russia"> Russia </option>

                <option value="Rwanda"> Rwanda </option>

                <option value="Saint Barthelemy"> Saint Barthelemy </option>

                <option value="Saint Helena"> Saint Helena </option>

                <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>

                <option value="Saint Lucia"> Saint Lucia </option>

                <option value="Saint Martin"> Saint Martin </option>

                <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>

                <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>

                <option value="Samoa"> Samoa </option>

                <option value="San Marino"> San Marino </option>

                <option value="Sao Tome and Principe"> Sao Tome and Principe </option>

                <option value="Saudi Arabia"> Saudi Arabia </option>

                <option value="Senegal"> Senegal </option>

                <option value="Serbia"> Serbia </option>

                <option value="Seychelles"> Seychelles </option>

                <option value="Sierra Leone"> Sierra Leone </option>

                <option value="Singapore"> Singapore </option>

                <option value="Slovakia"> Slovakia </option>

                <option value="Slovenia"> Slovenia </option>

                <option value="Solomon Islands"> Solomon Islands </option>

                <option value="Somalia"> Somalia </option>

                <option value="Somaliland"> Somaliland </option>

                <option value="South Africa"> South Africa </option>

                <option value="South Ossetia"> South Ossetia </option>

                <option value="Spain"> Spain </option>

                <option value="Sri Lanka"> Sri Lanka </option>

                <option value="Sudan"> Sudan </option>

                <option value="Suriname"> Suriname </option>

                <option value="Svalbard"> Svalbard </option>

                <option value="Swaziland"> Swaziland </option>

                <option value="Sweden"> Sweden </option>

                <option value="Switzerland"> Switzerland </option>

                <option value="Syria"> Syria </option>

                <option value="Taiwan"> Taiwan </option>

                <option value="Tajikistan"> Tajikistan </option>

                <option value="Tanzania"> Tanzania </option>

                <option value="Thailand"> Thailand </option>

                <option value="Timor-Leste"> Timor-Leste </option>

                <option value="Togo"> Togo </option>

                <option value="Tokelau"> Tokelau </option>

                <option value="Tonga"> Tonga </option>

                <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>

                <option value="Trinidad and Tobago"> Trinidad and Tobago </option>

                <option value="Tristan da Cunha"> Tristan da Cunha </option>

                <option value="Tunisia"> Tunisia </option>

                <option value="Turkey"> Turkey </option>

                <option value="Turkmenistan"> Turkmenistan </option>

                <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>

                <option value="Tuvalu"> Tuvalu </option>

                <option value="Uganda"> Uganda </option>

                <option value="Ukraine"> Ukraine </option>

                <option value="United Arab Emirates"> United Arab Emirates </option>

                <option value="United Kingdom"> United Kingdom </option>

                <option value="Uruguay"> Uruguay </option>

                <option value="Uzbekistan"> Uzbekistan </option>

                <option value="Vanuatu"> Vanuatu </option>

                <option value="Vatican City"> Vatican City </option>

                <option value="Venezuela"> Venezuela </option>

                <option value="Vietnam"> Vietnam </option>

                <option value="British Virgin Islands"> British Virgin Islands </option>

                <option value="US Virgin Islands"> US Virgin Islands </option>

                <option value="Wallis and Futuna"> Wallis and Futuna </option>

                <option value="Western Sahara"> Western Sahara </option>

                <option value="Yemen"> Yemen </option>

                <option value="Zambia"> Zambia </option>

                <option value="Zimbabwe"> Zimbabwe </option>

              </select>

            </div>

          </li>

          <li class="form-line" id="id_175">

            <label class="form-label-top" id="label_175" for="input_175"> Date of Birth </label>

            <div id="cid_175" class="form-input-wide"><span class="form-sub-label-container"><select class="form-dropdown" name="q175_dateOf[month]" id="input_175_month">

                  <option>  </option>

                  <option value="January"> January </option>

                  <option value="February"> February </option>

                  <option value="March"> March </option>

                  <option value="April"> April </option>

                  <option value="May"> May </option>

                  <option value="June"> June </option>

                  <option value="July"> July </option>

                  <option value="August"> August </option>

                  <option value="September"> September </option>

                  <option value="October"> October </option>

                  <option value="November"> November </option>

                  <option value="December"> December </option>

                </select>

                <label class="form-sub-label" for="input_175_month" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q175_dateOf[day]" id="input_175_day">

                  <option>  </option>

                  <option value="1"> 1 </option>

                  <option value="2"> 2 </option>

                  <option value="3"> 3 </option>

                  <option value="4"> 4 </option>

                  <option value="5"> 5 </option>

                  <option value="6"> 6 </option>

                  <option value="7"> 7 </option>

                  <option value="8"> 8 </option>

                  <option value="9"> 9 </option>

                  <option value="10"> 10 </option>

                  <option value="11"> 11 </option>

                  <option value="12"> 12 </option>

                  <option value="13"> 13 </option>

                  <option value="14"> 14 </option>

                  <option value="15"> 15 </option>

                  <option value="16"> 16 </option>

                  <option value="17"> 17 </option>

                  <option value="18"> 18 </option>

                  <option value="19"> 19 </option>

                  <option value="20"> 20 </option>

                  <option value="21"> 21 </option>

                  <option value="22"> 22 </option>

                  <option value="23"> 23 </option>

                  <option value="24"> 24 </option>

                  <option value="25"> 25 </option>

                  <option value="26"> 26 </option>

                  <option value="27"> 27 </option>

                  <option value="28"> 28 </option>

                  <option value="29"> 29 </option>

                  <option value="30"> 30 </option>

                  <option value="31"> 31 </option>

                </select>

                <label class="form-sub-label" for="input_175_day" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q175_dateOf[year]" id="input_175_year">

                  <option>  </option>

                  <option value="2038"> 2038 </option>

                  <option value="2037"> 2037 </option>

                  <option value="2036"> 2036 </option>

                  <option value="2035"> 2035 </option>

                  <option value="2034"> 2034 </option>

                  <option value="2033"> 2033 </option>

                  <option value="2032"> 2032 </option>

                  <option value="2031"> 2031 </option>

                  <option value="2030"> 2030 </option>

                  <option value="2029"> 2029 </option>

                  <option value="2028"> 2028 </option>

                  <option value="2027"> 2027 </option>

                  <option value="2026"> 2026 </option>

                  <option value="2025"> 2025 </option>

                  <option value="2024"> 2024 </option>

                  <option value="2023"> 2023 </option>

                  <option value="2022"> 2022 </option>

                  <option value="2021"> 2021 </option>

                  <option value="2020"> 2020 </option>

                  <option value="2019"> 2019 </option>

                  <option value="2018"> 2018 </option>

                  <option value="2017"> 2017 </option>

                  <option value="2016"> 2016 </option>

                  <option value="2015"> 2015 </option>

                  <option value="2014"> 2014 </option>

                  <option value="2013"> 2013 </option>

                  <option value="2012"> 2012 </option>

                  <option value="2011"> 2011 </option>

                  <option value="2010"> 2010 </option>

                  <option value="2009"> 2009 </option>

                  <option value="2008"> 2008 </option>

                  <option value="2007"> 2007 </option>

                  <option value="2006"> 2006 </option>

                  <option value="2005"> 2005 </option>

                  <option value="2004"> 2004 </option>

                  <option value="2003"> 2003 </option>

                  <option value="2002"> 2002 </option>

                  <option value="2001"> 2001 </option>

                  <option value="2000"> 2000 </option>

                  <option value="1999"> 1999 </option>

                  <option value="1998"> 1998 </option>

                  <option value="1997"> 1997 </option>

                  <option value="1996"> 1996 </option>

                  <option value="1995"> 1995 </option>

                  <option value="1994"> 1994 </option>

                  <option value="1993"> 1993 </option>

                  <option value="1992"> 1992 </option>

                  <option value="1991"> 1991 </option>

                  <option value="1990"> 1990 </option>

                  <option value="1989"> 1989 </option>

                  <option value="1988"> 1988 </option>

                  <option value="1987"> 1987 </option>

                  <option value="1986"> 1986 </option>

                  <option value="1985"> 1985 </option>

                  <option value="1984"> 1984 </option>

                  <option value="1983"> 1983 </option>

                  <option value="1982"> 1982 </option>

                  <option value="1981"> 1981 </option>

                  <option value="1980"> 1980 </option>

                  <option value="1979"> 1979 </option>

                  <option value="1978"> 1978 </option>

                  <option value="1977"> 1977 </option>

                  <option value="1976"> 1976 </option>

                  <option value="1975"> 1975 </option>

                  <option value="1974"> 1974 </option>

                  <option value="1973"> 1973 </option>

                  <option value="1972"> 1972 </option>

                  <option value="1971"> 1971 </option>

                  <option value="1970"> 1970 </option>

                  <option value="1969"> 1969 </option>

                  <option value="1968"> 1968 </option>

                  <option value="1967"> 1967 </option>

                  <option value="1966"> 1966 </option>

                  <option value="1965"> 1965 </option>

                  <option value="1964"> 1964 </option>

                  <option value="1963"> 1963 </option>

                  <option value="1962"> 1962 </option>

                  <option value="1961"> 1961 </option>

                  <option value="1960"> 1960 </option>

                  <option value="1959"> 1959 </option>

                  <option value="1958"> 1958 </option>

                  <option value="1957"> 1957 </option>

                  <option value="1956"> 1956 </option>

                  <option value="1955"> 1955 </option>

                  <option value="1954"> 1954 </option>

                  <option value="1953"> 1953 </option>

                  <option value="1952"> 1952 </option>

                  <option value="1951"> 1951 </option>

                  <option value="1950"> 1950 </option>

                  <option value="1949"> 1949 </option>

                  <option value="1948"> 1948 </option>

                  <option value="1947"> 1947 </option>

                  <option value="1946"> 1946 </option>

                  <option value="1945"> 1945 </option>

                  <option value="1944"> 1944 </option>

                  <option value="1943"> 1943 </option>

                  <option value="1942"> 1942 </option>

                  <option value="1941"> 1941 </option>

                  <option value="1940"> 1940 </option>

                  <option value="1939"> 1939 </option>

                  <option value="1938"> 1938 </option>

                  <option value="1937"> 1937 </option>

                  <option value="1936"> 1936 </option>

                  <option value="1935"> 1935 </option>

                  <option value="1934"> 1934 </option>

                  <option value="1933"> 1933 </option>

                  <option value="1932"> 1932 </option>

                  <option value="1931"> 1931 </option>

                  <option value="1930"> 1930 </option>

                  <option value="1929"> 1929 </option>

                  <option value="1928"> 1928 </option>

                  <option value="1927"> 1927 </option>

                  <option value="1926"> 1926 </option>

                  <option value="1925"> 1925 </option>

                  <option value="1924"> 1924 </option>

                  <option value="1923"> 1923 </option>

                  <option value="1922"> 1922 </option>

                  <option value="1921"> 1921 </option>

                  <option value="1920"> 1920 </option>

                </select>

                <label class="form-sub-label" for="input_175_year" id="sublabel_year"> Year </label></span>

            </div>

          </li>

          <li class="form-line" id="id_176">

            <label class="form-label-top" id="label_176" for="input_176"> Sex </label>

            <div id="cid_176" class="form-input-wide">

              <select class="form-dropdown" style="width:150px" id="input_176" name="q176_sex">

                <option value="">  </option>

                <option value="Male"> Male </option>

                <option value="Female"> Female </option>

                <option value="N/A"> N/A </option>

              </select>

            </div>

          </li>

          <li class="form-line" id="id_169">

            <label class="form-label-top" id="label_169" for="input_169"> Phone Number </label>

            <div id="cid_169" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_169" name="q169_phoneNumber" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_170">

            <label class="form-label-top" id="label_170" for="input_170"> Email address </label>

            <div id="cid_170" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_170" name="q170_emailAddress" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_171">

            <label class="form-label-top" id="label_171" for="input_171"> Skype Name </label>

            <div id="cid_171" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_171" name="q171_skypeName" size="50" value="">

            </div>

          </li>

          <li class="form-line" id="id_172">

            <label class="form-label-top" id="label_172" for="input_172"> Google + Name </label>

            <div id="cid_172" class="form-input-wide">

              <input type="text" class=" form-textbox" data-type="input-textbox" id="input_172" name="q172_google" size="50" value="">

            </div>

          </li>

          <li id="cid_3" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_3" class="form-header">

                Surgical Patients Only:

              </h2>

            </div>

          </li>

          <li id="cid_4" class="form-input-wide">

            <div class="form-header-group">

              <h3 id="header_4" class="form-header">

                Please check the weight loss procedure that you are interested in:

              </h3>

            </div>

          </li>

          <li class="form-line form-line-column" id="id_5">

            <label class="form-label-top" id="label_5" for="input_5"> Plesase check this: </label>

            <div id="cid_5" class="form-input-wide">

              <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_0" name="q5_plesaseCheck[]" value="Gastric Bypass">

                  <label for="input_5_0"> Gastric Bypass </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_1" name="q5_plesaseCheck[]" value="Lap Band">

                  <label for="input_5_1"> Lap Band </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_2" name="q5_plesaseCheck[]" value="Undecided">

                  <label for="input_5_2"> Undecided </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_3" name="q5_plesaseCheck[]" value="Revision of Previous Surgery">

                  <label for="input_5_3"> Revision of Previous Surgery </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_4" name="q5_plesaseCheck[]" value="Gastric Sleeve">

                  <label for="input_5_4"> Gastric Sleeve </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_5" name="q5_plesaseCheck[]" value="Gastric Plication">

                  <label for="input_5_5"> Gastric Plication </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_6" name="q5_plesaseCheck[]" value="Mini Gastric Bypass">

                  <label for="input_5_6"> Mini Gastric Bypass </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_7" name="q5_plesaseCheck[]" value="Duodenal Switch">

                  <label for="input_5_7"> Duodenal Switch </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_5_8" name="q5_plesaseCheck[]" value="Remove lapband">

                  <label for="input_5_8"> Remove lapband </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li id="cid_6" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_6" class="form-header">

                Medical History (please circle yes or no to the following questions)

              </h2>

            </div>

          </li>

          <li id="cid_10" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_10" class="form-header">

                Nervous System:

              </h2>

            </div>

          </li>

          <li class="form-line" id="id_12">

            <label class="form-label-top" id="label_12" for="input_12"> Stroke, mini stroke, or one-sided weakness? </label>

            <div id="cid_12" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_0" name="q12_strokeMini" value="Yes">

                  <label for="input_12_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_1" name="q12_strokeMini" value="No">

                  <label for="input_12_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_18">

            <label class="form-label-top" id="label_18" for="input_18"> Chronic headaches/migraines? </label>

            <div id="cid_18" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_18_0" name="q18_chronicHeadachesmigraines" value="Yes">

                  <label for="input_18_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_18_1" name="q18_chronicHeadachesmigraines" value="No">

                  <label for="input_18_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_14">

            <label class="form-label-top" id="label_14" for="input_14"> Seizures? </label>

            <div id="cid_14" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_14_0" name="q14_seizures" value="Yes">

                  <label for="input_14_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_14_1" name="q14_seizures" value="No">

                  <label for="input_14_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_20">

            <label class="form-label-top" id="label_20" for="input_20"> Numbness or tingling in neck, arms, or hands? </label>

            <div id="cid_20" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_0" name="q20_numbnessOr" value="Yes">

                  <label for="input_20_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_1" name="q20_numbnessOr" value="No">

                  <label for="input_20_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li id="cid_21" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_21" class="form-header">

                Heart and Circulation:

              </h2>

            </div>

          </li>

          <li class="form-line" id="id_23">

            <label class="form-label-top" id="label_23" for="input_23"> High blood pressure? </label>

            <div id="cid_23" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_23_0" name="q23_highBlood" value="Yes">

                  <label for="input_23_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_23_1" name="q23_highBlood" value="No">

                  <label for="input_23_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_28">

            <label class="form-label-top" id="label_28" for="input_28"> High cholesterol? </label>

            <div id="cid_28" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_28_0" name="q28_highCholesterol" value="Yes">

                  <label for="input_28_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_28_1" name="q28_highCholesterol" value="No">

                  <label for="input_28_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_27">

            <label class="form-label-top" id="label_27" for="input_27"> Congestive heart failure? </label>

            <div id="cid_27" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_27_0" name="q27_congestiveHeart" value="Yes">

                  <label for="input_27_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_27_1" name="q27_congestiveHeart" value="No">

                  <label for="input_27_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_26">

            <label class="form-label-top" id="label_26" for="input_26"> Heart attack? </label>

            <div id="cid_26" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_26_0" name="q26_heartAttack" value="Yes">

                  <label for="input_26_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_26_1" name="q26_heartAttack" value="No">

                  <label for="input_26_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_25">

            <label class="form-label-top" id="label_25" for="input_25"> Heart valve abnormalities? </label>

            <div id="cid_25" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_25_0" name="q25_heartValve" value="Yes">

                  <label for="input_25_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_25_1" name="q25_heartValve" value="No">

                  <label for="input_25_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_24">

            <label class="form-label-top" id="label_24" for="input_24"> Abnormal heart rhythms? </label>

            <div id="cid_24" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_24_0" name="q24_abnormalHeart" value="Yes">

                  <label for="input_24_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_24_1" name="q24_abnormalHeart" value="No">

                  <label for="input_24_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_29">

            <label class="form-label-top" id="label_29" for="input_29"> Symptoms with exercise? </label>

            <div id="cid_29" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_29_0" name="q29_symptomsWith" value="Yes">

                  <label for="input_29_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_29_1" name="q29_symptomsWith" value="No">

                  <label for="input_29_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_30">

            <label class="form-label-top" id="label_30" for="input_30"> If yes, explain: </label>

            <div id="cid_30" class="form-input-wide">

              <textarea id="input_30" class="form-textarea" name="q30_ifYes" cols="73" rows="6"></textarea>

            </div>

          </li>

          <li class="form-line" id="id_31">

            <label class="form-label-top" id="label_31" for="input_31"> Heart stress test? </label>

            <div id="cid_31" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_31_0" name="q31_heartStress" value="Yes">

                  <label for="input_31_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_31_1" name="q31_heartStress" value="No">

                  <label for="input_31_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_32">

            <label class="form-label-top" id="label_32" for="input_32"> Cardiac catheterization or angioplasty? </label>

            <div id="cid_32" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_32_0" name="q32_cardiacCatheterization" value="Yes">

                  <label for="input_32_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_32_1" name="q32_cardiacCatheterization" value="No">

                  <label for="input_32_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_33">

            <label class="form-label-top" id="label_33" for="input_33"> Pacemaker or implantable defibrillator? </label>

            <div id="cid_33" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_33_0" name="q33_pacemakerOr" value="Yes">

                  <label for="input_33_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_33_1" name="q33_pacemakerOr" value="No">

                  <label for="input_33_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li id="cid_34" class="form-input-wide">

            <div class="form-header-group">

              <h2 id="header_34" class="form-header">

                Lungs and Breathing:

              </h2>

            </div>

          </li>

          <li class="form-line" id="id_36">

            <label class="form-label-top" id="label_36" for="input_36"> Sleep apnea? </label>

            <div id="cid_36" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_36_0" name="q36_sleepApnea" value="Yes">

                  <label for="input_36_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_36_1" name="q36_sleepApnea" value="No">

                  <label for="input_36_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_37">

            <label class="form-label-top" id="label_37" for="input_37"> CPAP or BIPAP machine? </label>

            <div id="cid_37" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_37_0" name="q37_cpapOr" value="Yes">

                  <label for="input_37_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_37_1" name="q37_cpapOr" value="No">

                  <label for="input_37_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_38">

            <label class="form-label-top" id="label_38" for="input_38"> Have you ever had a sleep study? </label>

            <div id="cid_38" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_38_0" name="q38_haveYou" value="Yes">

                  <label for="input_38_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_38_1" name="q38_haveYou" value="No">

                  <label for="input_38_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_39">

            <label class="form-label-top" id="label_39" for="input_39"> Asthma? </label>

            <div id="cid_39" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_39_0" name="q39_asthma" value="Yes">

                  <label for="input_39_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_39_1" name="q39_asthma" value="No">

                  <label for="input_39_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_40">

            <label class="form-label-top" id="label_40" for="input_40"> Emphysema or COPD? </label>

            <div id="cid_40" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_40_0" name="q40_emphysemaOr" value="Yes">

                  <label for="input_40_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_40_1" name="q40_emphysemaOr" value="No">

                  <label for="input_40_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_41">

            <label class="form-label-top" id="label_41" for="input_41"> Pulmonary embolus? </label>

            <div id="cid_41" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_41_0" name="q41_pulmonaryEmbolus" value="Yes">

                  <label for="input_41_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_41_1" name="q41_pulmonaryEmbolus" value="No">

                  <label for="input_41_1"> No </label></span><span class="clearfix"></span>

              </div>

            </div>

          </li>

          <li class="form-line" id="id_42">

            <label class="form-label-top" id="label_42" for="input_42"> How many blocks can you walk without becoming short of breath? </label>

            <div id="cid_42" class="form-input-wide">

              <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_42_0" name="q42_howMany

  • Profile Image
    EliezerN
    Answered on March 17, 2014 at 11:26 AM

    Hi,

    We would appreciate if next time you share a long code of a form or of a webpage, you use http://pastiebin.com/ to save the code there and then share the link with us. That will avoid a very long message/thread.

    So, if you wish to clone/copy a form, all you need is the form URL. In this case the URL of the form you wish to clone is this one http://www.jotform.me/form/31345264095453

    Here is how to clone a form: How to clone an existing form from a URL

    Inform us if you need further assistance with this inquiry.

    Thanks