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{"id":443,"date":"2019-10-01T11:21:04","date_gmt":"2019-10-01T09:21:04","guid":{"rendered":"http:\/\/galpharma.tn\/?page_id=443"},"modified":"2024-07-15T14:57:56","modified_gmt":"2024-07-15T12:57:56","slug":"pharmacovigilance","status":"publish","type":"page","link":"https:\/\/galpharma.tn\/en\/pharmacovigilance\/","title":{"rendered":"Pharmacovigilance"},"content":{"rendered":"<div class=\"container notification_pv\"><script type=\"text\/javascript\" name=\"js_con\">\r\n\t\r\n\tfunction run_nf_conditional_logic8(){\r\n\t\t\t\r\n\t\t}\r\n\t\tjQuery(document).ready(\r\nfunction()\r\n\t{\r\n\t\t\r\n\t}\r\n\t);\r\n\t\t\t\t<\/script>\r\n\t<div class=\"pre_fill_fields\"><\/div><div id=\"the_plugin_url\" style=\"display:none;\">https:\/\/galpharma.tn\/wp-content\/plugins\/nex-forms<\/div><div id=\"nex-forms\" class=\"nex-forms\"><div id=\"confirmation_page\" class=\"confirmation_page\" style=\"display:none;\"><\/div><div id=\"on_form_submmision\" class=\"on_form_submmision\" style=\"display:none;\">message<\/div><div class=\"ui-nex-forms-container\" id=\"ui-nex-forms-container\"  ><div class=\"current_step\" style=\"display:none;\">1<\/div><div class=\"panel-body alert alert-success nex_success_message\" style=\"display:none;\"><div class=\"form_field all_fields icon html_fields wow bounceInUp\" style=\"margin-bottom: 15px;\" id=\"_21501\" data-animation-name=\"bounceInUp\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"icon_container_wrapper icon_center\">\n\t\t\t\t\t\t\t\t  <div class=\"icon_container\" id=\"field_container\" style=\"border-width: 0px; background-color: transparent;\">\n\t\t\t\t\t\t\t\t\t<div class=\"\">\n\t\t\t\t\t\t\t\t\t  <div class=\"input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element icon_element\" style=\"font-size: 50px; color: #8bc34a;\"><span class=\"fas fa-check-circle\"><\/span><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields html html_fields wow fadeInDown\" style=\"margin-bottom: 15px;\" data-animation-name=\"fadeInDown\" data-wow-delay=\"0.5s\" id=\"_99498\">\n\t\t\t\t\t\t\t  <div class=\"edit_mask\"><\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t  <div class=\"col-sm-12\" id=\"field_container\">\n\t\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t  <div class=\"col-sm-12 input_container\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"the_input_element align_center\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\">Thank you for connecting with us. We will respond to you shortly.<\/div>\n\t\t\t\t\t\t\t\t\t\t<div style=\"clear:both;\"><\/div>\n\t\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t  <\/div>\n\t\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t  \n\t\t\t\t\t\t\t<\/div><\/div><div class=\"hidden\" id=\"nf_ajax_url\">https:\/\/galpharma.tn\/wp-admin\/admin-ajax.php<\/div><form id=\"nf_form_86253\" class=\"submit-nex-form\" name=\"nex_form\" action=\"https:\/\/galpharma.tn\/wp-admin\/admin-ajax.php\" method=\"post\" enctype=\"multipart\/form-data\"><input type=\"hidden\" name=\"nex_forms_Id\" value=\"45\"><input type=\"hidden\" name=\"page\" value=\"\/en\/wp-json\/wp\/v2\/pages\/443\"><input type=\"hidden\" name=\"ip\" value=\"216.73.216.12\"><input type=\"text\" name=\"company_url\" value=\"\" placeholder=\"enter company url\" class=\"form-control req\">\n\t\t\t\t\t\t\t<div class=\"form_field hidden\" style=\"\" data-id=\"_95093\" id=\"_95093\">\n\t\t\t\t\t\t\t\t<input class=\"ms_current_step\" value=\"1\" name=\"ms_current_step\" type=\"hidden\" autocomplete=\"enabled\" id=\"_95093__ms_current_step\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" data-id=\"_14423\" id=\"_14423\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_14423__math_result\"><h1 class=\"the_input_element\" data-math-equation=\"\" data-original-math-equation=\"\" data-decimal-places=\"0\" style=\"font-size: 20px;\">Fiche de pr\u00e9somption d\u2019effets ind\u00e9sirables des m\u00e9dicaments<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields date special_fields has_prefix_icon required\" style=\"margin-bottom: 15px;\" data-id=\"_99695\" id=\"_99695\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__99695\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">*Date du premier reporting ou date de r\u00e9ception du cas PV :             <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_du_premier_reportin\" class=\"error_message form-control the_input_element aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__99695\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" data-id=\"_7682\" id=\"_7682\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_7682__math_result\"><h2 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">NB : La date du premier reporting est importante, veuillez s\u2019il vous pla\u00eet la remplir ainsi que pr\u00e9ciser votre identit\u00e9 dans le tableau ci-dessous <\/h2><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_65207\" id=\"_65207\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" data-id=\"_87069\" id=\"_87069\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_87069__math_result\"><h3 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Notificateur<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-4 is_grid\" style=\"position: relative; left: 0px; top: 0px;\" data-id=\"_78201\" id=\"_78201\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_78201  col-sm-3 grid-target-0\" data-grid-width=\"3\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px;\" data-id=\"_75446\" id=\"_75446\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__75446\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">*Nom<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"nom\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__75446\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78201  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields required\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_14177\" id=\"_14177\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__14177\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">*Qualification\/sp\u00e9cialit\u00e9<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"qualificationspecialite\" class=\"form-control error_message the_input_element aling_left align_left required\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__14177\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78201  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields phone_number phone_number preset_fields required\" style=\"margin-bottom: 15px;\" data-id=\"_58201\" id=\"_58201\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__58201\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">*T\u00e9l<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"t\u00e9l\" class=\"error_message phone_number form-control the_input_element aling_left align_left required\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__58201\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_78201  col-sm-3 grid-target-3\" data-grid-width=\"3\" data-grid-num=\"3\"><div class=\"form_field all_fields email email preset_fields required\" style=\"margin-bottom: 15px;\" data-id=\"_83302\" id=\"_83302\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__83302\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">*Email<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"email\" class=\"error_message required email form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid email address\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__83302\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_33372\" id=\"_33372\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_33372__math_result\"><h3 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Identification du patient<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-4 is_grid\" style=\"position: relative; top: 0px;\" data-id=\"_84499\" id=\"_84499\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_84499  col-sm-3 grid-target-0\" data-grid-width=\"3\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_268\" id=\"_268\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__268\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Initiales<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"initiales\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__268\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_63239\" id=\"_63239\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Sexe<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__63239_sexe_M_m\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"sexe\" id=\"__45__63239_sexe_M_m\" value=\"M\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">M<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__63239_sexe_F_f\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"sexe\" id=\"__45__63239_sexe_F_f\" value=\"F\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">F<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_84499  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_88874\" id=\"_88874\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__88874\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date de naissance<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"date no-icon\" id=\"datetimepicker\" data-language=\"en\" data-format=\"DD\/MM\/YYYY\"><input type=\"text\" name=\"date_de_naissance\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__88874\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_51089\" id=\"_51089\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__51089\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Poids<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"poids\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__51089\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_84499  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields phone_number phone_number preset_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_79986\" id=\"_79986\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__79986\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">T\u00e9l<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"t\u00e9l\" class=\"error_message phone_number form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid phone number\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__79986\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_25533\" id=\"_25533\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__25533\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Taille<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"taille\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__25533\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_84499  col-sm-3 grid-target-3\" data-grid-width=\"3\" data-grid-num=\"3\"><div class=\"form_field all_fields email email preset_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" data-id=\"_8633\" id=\"_8633\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__8633\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Email<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"email\" class=\"error_message email form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" data-secondary-message=\"Invalid email address\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__8633\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" data-id=\"_29678\" id=\"_29678\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__29678\"><span class=\"the_label style_bold\" style=\"font-size: 13px; color: #5b5b5b;\">Diagnostic retenu<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"diagnostic_retenu\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 13px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__29678\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px;\" data-id=\"_35206\" id=\"_35206\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_45824\" id=\"_45824\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_45824__math_result\"><h3 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Medicaments prescrits en relation avec l\u2019ordonnance :<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-1 is_grid\" style=\"position: relative; left: 0px; top: 0px;\" data-id=\"_43309\" id=\"_43309\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-0\" data-grid-width=\"2\" data-grid-num=\"0\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_23806\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_23806__math_result\"><h4 style=\"font-size: 14px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">M\u00e9dicament(s)<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_23266\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_23266__pm1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_5209\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_5209__pm2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_82149\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_82149__pm3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_47841\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_47841__pm4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_72589\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_72589__pm5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_49328\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pm6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_49328__pm6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-1\" data-grid-width=\"2\" data-grid-num=\"1\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_50216\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_50216__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Voie d\u2019administration<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_82784\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_82784__pv1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_46963\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_46963__pv2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_52091\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_52091__pv3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_31946\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_31946__pv4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_86411\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_86411__pv5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_80312\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pv6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_80312__pv6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-2\" data-grid-width=\"2\" data-grid-num=\"2\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_3007\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_3007__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Posologie<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_27356\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_27356__pp1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_79296\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_79296__pp2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_1365\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_1365__pp3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_45821\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_45821__pp4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_81944\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_81944__pp5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_90035\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pp6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_90035__pp6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-3\" data-grid-width=\"2\" data-grid-num=\"3\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_97533\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_97533__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">D\u00e9but d\u2019administration<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_89798\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_89798__pd1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_86206\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_86206__pd2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_67904\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_67904__pd3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_68154\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_68154__pd4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_41360\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_41360__pd5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_1342\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pd6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_1342__pd6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-4\" data-grid-width=\"2\" data-grid-num=\"4\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_47920\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_47920__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Fin d\u2019administration *<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_98826\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_98826__pf1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_51424\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_51424__pf2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_20256\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_20256__pf3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_48823\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_48823__pf4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields moving_batch\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_12408\" data-bath-pos=\"0\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_12408__pf5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_85169\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pf6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_85169__pf6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_43309  col-sm-2 grid-target-5\" data-grid-width=\"2\" data-grid-num=\"5\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_5783\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_5783__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Indication<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_58613\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_58613__pi1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_37059\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_37059__pi2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_84941\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_84941__pi3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_78692\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_78692__pi4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_33262\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_33262__pi5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_64738\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"pi6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_64738__pi6\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" data-id=\"_13340\" id=\"_13340\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_13340__math_result\"><h3 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Medicaments concomittants :<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-1 is_grid\" style=\"position: relative; left: 0px; top: 0px;\" data-id=\"_43309\" id=\"_97705\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-0\" data-grid-width=\"2\" data-grid-num=\"0\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_46269\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_46269__math_result\"><h4 style=\"font-size: 14px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">M\u00e9dicament(s)<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_52193\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_52193__cm1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_65344\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_65344__cm2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_37080\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_37080__cm3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_99398\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_99398__cm4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_17530\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_17530__cm5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_89353\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cm6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_89353__cm6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-1\" data-grid-width=\"2\" data-grid-num=\"1\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_43854\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_43854__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Voie d\u2019administration<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_54694\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_54694__cv1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_26190\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_26190__cv2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_83020\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_83020__cv3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_96894\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_96894__cv4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_44823\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_44823__cv5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_26038\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cv6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_26038__cv6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-2\" data-grid-width=\"2\" data-grid-num=\"2\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_53407\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_53407__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Posologie<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_36035\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_36035__cp1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_85427\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_85427__cp2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_33604\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_33604__cp3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_53951\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_53951__cp4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_84589\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_84589__cp5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_28485\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cp6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_28485__cp6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-3\" data-grid-width=\"2\" data-grid-num=\"3\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_56605\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_56605__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">D\u00e9but d\u2019administration<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_54787\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_54787__cd1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_73420\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_73420__cd2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_65430\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_65430__cd3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_9278\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_9278__cd4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_51252\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_51252__cd5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_25553\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cd6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_25553__cd6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-4\" data-grid-width=\"2\" data-grid-num=\"4\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_27239\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_27239__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Fin d\u2019administration *<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_43471\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_43471__cf1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_17979\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_17979__cf2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_70436\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_70436__cf3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_52175\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_52175__cf4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields moving_batch\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_30807\" data-bath-pos=\"0\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_30807__cf5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_78026\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"cf6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_78026__cf6\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_97705  col-sm-2 grid-target-5\" data-grid-width=\"2\" data-grid-num=\"5\"><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_22768\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_22768__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Indication<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_32152\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci1\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_32152__ci1\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_71051\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci2\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_71051__ci2\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_44203\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci3\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_44203__ci3\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_72304\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci4\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_72304__ci4\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_8941\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci5\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_8941__ci5\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_72338\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"input_container col-sm-12\"><input type=\"text\" name=\"ci6\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" autocomplete=\"enabled\" id=\"_72338__ci6\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px;\" id=\"_83349\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_13216\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_13216__math_result\"><h2 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Antecedents du patient<\/h2><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_81043\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__81043\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Ant\u00e9c\u00e9dents m\u00e9dicaux <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"ant\u00e9c\u00e9dents_m\u00e9dicaux_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__81043\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_61437\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__61437\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Ant\u00e9c\u00e9dents chirurgicaux <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"ant\u00e9c\u00e9dents_chirurgicaux_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__61437\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_97651\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__97651\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Autres \u00e0 sp\u00e9cifier<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"autres_\u00e0_sp\u00e9cifier\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__97651\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px;\" id=\"_65948\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_76950\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_76950__math_result\"><h3 style=\"font-size: 16px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Devant l\u2019apparition de l\u2019effet indesirable, quelle etait la conduite a tenir concernant le medicament suspect ? <\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px;\" id=\"_44676\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Choisir un ou plusieurs choix<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Arr\u00eat du m\u00e9dicament_arr\u00eat_du_m\u00e9dicament\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"choisir_un_ou_plusieurs_choix[]\" id=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Arr\u00eat du m\u00e9dicament_arr\u00eat_du_m\u00e9dicament\" value=\"Arr\u00eat du m\u00e9dicament\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Arr\u00eat du m\u00e9dicament<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Diminution de posologie_diminution_de_posologie\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"choisir_un_ou_plusieurs_choix[]\" id=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Diminution de posologie_diminution_de_posologie\" value=\"Diminution de posologie\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Diminution de posologie<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Traitement symptomatique_traitement_symptomatique\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"choisir_un_ou_plusieurs_choix[]\" id=\"__45__44676_choisir_un_ou_plusieurs_choix[]_Traitement symptomatique_traitement_symptomatique\" value=\"Traitement symptomatique\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Traitement symptomatique<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_30659\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__30659\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Autre \u00e0 sp\u00e9cifier<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"autre_\u00e0_sp\u00e9cifier\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__30659\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; left: 0px; top: 0px;\" id=\"_10310\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_10310__math_result\"><h3 style=\"font-size: 16px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">En cas d\u2019arr\u00eat du medicament suspect, veuillez s\u2019il vous pla\u00eet pr\u00e9ciser s\u2019il y a eu une r\u00e9introduction du medicament suspect .<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_19947\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">R\u00e9ponse<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__19947_r\u00e9ponse_arret_Oui_oui\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_arret\" id=\"__45__19947_r\u00e9ponse_arret_Oui_oui\" value=\"Oui\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Oui<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__19947_r\u00e9ponse_arret_Non_non\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_arret\" id=\"__45__19947_r\u00e9ponse_arret_Non_non\" value=\"Non\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Non<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__19947_r\u00e9ponse_arret_Inconnu_inconnu\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_arret\" id=\"__45__19947_r\u00e9ponse_arret_Inconnu_inconnu\" value=\"Inconnu\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Inconnu<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_91773\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_91773__math_result\"><h3 style=\"font-size: 16px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">En cas de r\u00e9introduction du medicament suspect, veuillez s\u2019il vous pla\u00eet pr\u00e9ciser s\u2019il y a eu une r\u00e9apparition de l\u2019effet ind\u00e9sirable .<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_62170\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">R\u00e9ponse<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__62170_r\u00e9ponse_reintroduction_Oui_oui\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_reintroduction\" id=\"__45__62170_r\u00e9ponse_reintroduction_Oui_oui\" value=\"Oui\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Oui<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__62170_r\u00e9ponse_reintroduction_Non_non\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_reintroduction\" id=\"__45__62170_r\u00e9ponse_reintroduction_Non_non\" value=\"Non\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Non<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__62170_r\u00e9ponse_reintroduction_Inconnu_inconnu\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse_reintroduction\" id=\"__45__62170_r\u00e9ponse_reintroduction_Inconnu_inconnu\" value=\"Inconnu\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Inconnu<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_21530\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_21530__math_result\"><h3 style=\"font-size: 16px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Si le patient est un nouveau n\u00e9, veuillez s\u2019il vous pla\u00eet pr\u00e9ciser si le medicament a ete pris :<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_55759\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">R\u00e9ponse<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__55759_r\u00e9ponse_Par lui m\u00eame_par_lui_m\u00eame\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse\" id=\"__45__55759_r\u00e9ponse_Par lui m\u00eame_par_lui_m\u00eame\" value=\"Par lui m\u00eame\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Par lui m\u00eame<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__55759_r\u00e9ponse_Par sa m\u00e8re : pr\u00e9ciser le trimestre de grossesse                  _par_sa_m\u00e8re_:_pr\u00e9ciser_le_trimestre_de_grossesse__________________\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse\" id=\"__45__55759_r\u00e9ponse_Par sa m\u00e8re : pr\u00e9ciser le trimestre de grossesse                  _par_sa_m\u00e8re_:_pr\u00e9ciser_le_trimestre_de_grossesse__________________\" value=\"Par sa m\u00e8re : pr\u00e9ciser le trimestre de grossesse                  \" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Par sa m\u00e8re : pr\u00e9ciser le trimestre de grossesse                  <\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__55759_r\u00e9ponse_Pendant l\u2019allaitement_pendant_l\u2019allaitement\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"r\u00e9ponse\" id=\"__45__55759_r\u00e9ponse_Pendant l\u2019allaitement_pendant_l\u2019allaitement\" value=\"Pendant l\u2019allaitement\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Pendant l\u2019allaitement<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_74932\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_74932__math_result\"><h3 style=\"font-size: 16px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">\u00c9v\u00e9nement ind\u00e9sirable :<\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_7281\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_7281__math_result\"><h4 style=\"undefined\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Ev\u00e9nement <\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" id=\"_64552\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_64552  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields date special_fields has_prefix_icon\" style=\"margin-bottom: 15px;\" id=\"_22512\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__22512\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date de survenue <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_de_survenue_\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__22512\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_64552  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_80005\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__80005\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Dur\u00e9e<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"dur\u00e9e\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__80005\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px;\" id=\"_97108\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Gravit\u00e9<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_Hospitalisation ou prolongation d\u2019hospitalisation_hospitalisation_ou_prolongation_d\u2019hospitalisation\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_Hospitalisation ou prolongation d\u2019hospitalisation_hospitalisation_ou_prolongation_d\u2019hospitalisation\" value=\"Hospitalisation ou prolongation d\u2019hospitalisation\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Hospitalisation ou prolongation d\u2019hospitalisation<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_Incapacit\u00e9 ou invalidit\u00e9 permanente_incapacit\u00e9_ou_invalidit\u00e9_permanente\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_Incapacit\u00e9 ou invalidit\u00e9 permanente_incapacit\u00e9_ou_invalidit\u00e9_permanente\" value=\"Incapacit\u00e9 ou invalidit\u00e9 permanente\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Incapacit\u00e9 ou invalidit\u00e9 permanente<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_Mise en jeu du pronostic vital_mise_en_jeu_du_pronostic_vital\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_Mise en jeu du pronostic vital_mise_en_jeu_du_pronostic_vital\" value=\"Mise en jeu du pronostic vital\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Mise en jeu du pronostic vital<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_D\u00e9c\u00e8s_d\u00e9c\u00e8s\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_D\u00e9c\u00e8s_d\u00e9c\u00e8s\" value=\"D\u00e9c\u00e8s\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">D\u00e9c\u00e8s<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_Anomalie ou malformation Cong\u00e9nitale_anomalie_ou_malformation_cong\u00e9nitale\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_Anomalie ou malformation Cong\u00e9nitale_anomalie_ou_malformation_cong\u00e9nitale\" value=\"Anomalie ou malformation Cong\u00e9nitale\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Anomalie ou malformation Cong\u00e9nitale<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__97108_gravit\u00e9[]_Non grave_non_grave\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"gravit\u00e9[]\" id=\"__45__97108_gravit\u00e9[]_Non grave_non_grave\" value=\"Non grave\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Non grave<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px;\" id=\"_64585\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Evolution<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_Gu\u00e9rison_gu\u00e9rison\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_Gu\u00e9rison_gu\u00e9rison\" value=\"Gu\u00e9rison\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Gu\u00e9rison<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_Gu\u00e9rison en cours _gu\u00e9rison_en_cours_\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_Gu\u00e9rison en cours _gu\u00e9rison_en_cours_\" value=\"Gu\u00e9rison en cours \" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Gu\u00e9rison en cours <\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_Sujet non gu\u00e9ri_sujet_non_gu\u00e9ri\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_Sujet non gu\u00e9ri_sujet_non_gu\u00e9ri\" value=\"Sujet non gu\u00e9ri\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Sujet non gu\u00e9ri<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_D\u00e9c\u00e8s d\u00fb \u00e0 l\u2019effet _d\u00e9c\u00e8s_d\u00fb_\u00e0_l\u2019effet_\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_D\u00e9c\u00e8s d\u00fb \u00e0 l\u2019effet _d\u00e9c\u00e8s_d\u00fb_\u00e0_l\u2019effet_\" value=\"D\u00e9c\u00e8s d\u00fb \u00e0 l\u2019effet \" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">D\u00e9c\u00e8s d\u00fb \u00e0 l\u2019effet <\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_D\u00e9c\u00e8s sans rapport avec l\u2019effet_d\u00e9c\u00e8s_sans_rapport_avec_l\u2019effet\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_D\u00e9c\u00e8s sans rapport avec l\u2019effet_d\u00e9c\u00e8s_sans_rapport_avec_l\u2019effet\" value=\"D\u00e9c\u00e8s sans rapport avec l\u2019effet\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">D\u00e9c\u00e8s sans rapport avec l\u2019effet<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__64585_evolution[]_Inconnue_inconnue\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"evolution[]\" id=\"__45__64585_evolution[]_Inconnue_inconnue\" value=\"Inconnue\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Inconnue<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px;\" id=\"_54152\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Condition de Survenue<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_Conditions normales d\u2019utilisation _conditions_normales_d\u2019utilisation_\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_Conditions normales d\u2019utilisation _conditions_normales_d\u2019utilisation_\" value=\"Conditions normales d\u2019utilisation \" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Conditions normales d\u2019utilisation <\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_Erreur m\u00e9dicamenteuse _erreur_m\u00e9dicamenteuse_\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_Erreur m\u00e9dicamenteuse _erreur_m\u00e9dicamenteuse_\" value=\"Erreur m\u00e9dicamenteuse \" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Erreur m\u00e9dicamenteuse <\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_M\u00e9susage_m\u00e9susage\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_M\u00e9susage_m\u00e9susage\" value=\"M\u00e9susage\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">M\u00e9susage<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_Surdosage_surdosage\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_Surdosage_surdosage\" value=\"Surdosage\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Surdosage<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_Abus_abus\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_Abus_abus\" value=\"Abus\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Abus<\/span><\/span><\/label><label class=\"checkbox-inline radio-inline\" for=\"__45__54152_condition_de_survenue[]_Autre_autre\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"condition_de_survenue[]\" id=\"__45__54152_condition_de_survenue[]_Autre_autre\" value=\"Autre\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Autre<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px; position: relative; left: 0px; top: 0px;\" id=\"_22467\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__22467\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Nature et description detaillee de l\u2019evenement et de son evolution <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"nature_et_description_detaillee_de_l\u2019evenement_et_de_son_evolution_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__22467\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px;\" id=\"_33380\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields radio-group\" style=\"margin-bottom: 15px;\" id=\"_84091\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">En cas de grossesse<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__84091_check_boxes[]_Informations a compl\u00e9ter en cas de grossesse_informations_a_compl\u00e9ter_en_cas_de_grossesse\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"check_boxes[]\" id=\"__45__84091_check_boxes[]_Informations a compl\u00e9ter en cas de grossesse_informations_a_compl\u00e9ter_en_cas_de_grossesse\" value=\"Informations a compl\u00e9ter en cas de grossesse\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Informations a compl\u00e9ter en cas de grossesse<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"other-elements is_panel has_prefix_icon is_grid\" id=\"_88629\"><div class=\"row\"><div class=\"input_holder col-sm-12\"><div class=\"panel panel-default \"><div class=\"panel-heading\">Cas du grossesse<\/div><div class=\"panel-body the-panel-body\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_58789\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__58789\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Age actuel de la grossesse<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"age_actuel_de_la_grossesse\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__58789\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields check-group common_fields selection_fields moving_batch radio-group\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_33675\" data-bath-pos=\"0\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Echographie<\/span><\/label><\/div><div class=\"input_holder radio-group\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"alert-success\" data-checked-class=\"fa-check\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"Minimum of {x} selections required\" title=\"\"><div class=\"input-inner\"><label class=\"checkbox-inline radio-inline\" for=\"__45__33675_check_boxes[]_Si \u00e9chographie d\u00e9j\u00e0 faite, en pr\u00e9ciser la date et les r\u00e9sultats : Vous pouvez nous joindre les analyses effectu\u00e9es par mail \u00e0 l\u2019adresse : QPPV@galpharma.tn_si_\u00e9chographie_d\u00e9j\u00e0_faite_en_pr\u00e9ciser_la_date_et_les_r\u00e9sultats_:_vous_pouvez_nous_joindre_les_analyses_effectu\u00e9es_par_mail_\u00e0_l\u2019adresse_:_qppvgalpharmatn\"><span class=\"has-pretty-child\"><div class=\"clearfix prettycheckbox labelright blue has-pretty-child\"><input class=\"check the_input_element\" type=\"checkbox\" name=\"check_boxes[]\" id=\"__45__33675_check_boxes[]_Si \u00e9chographie d\u00e9j\u00e0 faite, en pr\u00e9ciser la date et les r\u00e9sultats : Vous pouvez nous joindre les analyses effectu\u00e9es par mail \u00e0 l\u2019adresse : QPPV@galpharma.tn_si_\u00e9chographie_d\u00e9j\u00e0_faite_en_pr\u00e9ciser_la_date_et_les_r\u00e9sultats_:_vous_pouvez_nous_joindre_les_analyses_effectu\u00e9es_par_mail_\u00e0_l\u2019adresse_:_qppvgalpharmatn\" value=\"Si \u00e9chographie d\u00e9j\u00e0 faite, en pr\u00e9ciser la date et les r\u00e9sultats : Vous pouvez nous joindre les analyses effectu\u00e9es par mail \u00e0 l\u2019adresse : QPPV@galpharma.tn\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label check-label\">Si \u00e9chographie d\u00e9j\u00e0 faite, en pr\u00e9ciser la date et les r\u00e9sultats : Vous pouvez nous joindre les analyses effectu\u00e9es par mail \u00e0 l\u2019adresse : QPPV@galpharma.tn<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields heading heading html_fields\" style=\"margin-bottom: 15px;\" id=\"_2003\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><input type=\"hidden\" class=\"set_math_result\" value=\"0\" name=\"math_result\" autocomplete=\"enabled\" id=\"_2003__math_result\"><h3 style=\"font-size: 14px;\" data-original-math-equation=\"\" data-math-equation=\"\" class=\"the_input_element\">Particularit\u00e9s de la grossesse actuelle <\/h3><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_7132\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__7132\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Issue de la grossesse<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"issue_de_la_grossesse\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__7132\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 has_prefix_icon is_grid\" style=\"\" id=\"_8879\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_8879  col-sm-8 grid-target-0\" data-grid-width=\"8\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_71936\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__71936\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Avortement spontan\u00e9<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"avortement_spontan\u00e9\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__71936\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_85443\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__85443\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Avortement provoqu\u00e9<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"avortement_provoqu\u00e9\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__85443\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_71473\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__71473\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Grossesse arr\u00eat\u00e9e<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"grossesse_arr\u00eat\u00e9e\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__71473\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_98952\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Accouchement<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__98952_accouchement_Voie basse_voie_basse\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"accouchement\" id=\"__45__98952_accouchement_Voie basse_voie_basse\" value=\"Voie basse\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Voie basse<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__98952_accouchement_C\u00e9sarienne_c\u00e9sarienne\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"accouchement\" id=\"__45__98952_accouchement_C\u00e9sarienne_c\u00e9sarienne\" value=\"C\u00e9sarienne\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">C\u00e9sarienne<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_8879  col-sm-4 grid-target-1\" data-grid-width=\"4\" data-grid-num=\"1\"><div class=\"form_field all_fields date special_fields has_prefix_icon\" style=\"margin-bottom: 15px;\" id=\"_35118\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__35118\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_av_sp\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__35118\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields date special_fields has_prefix_icon\" style=\"margin-bottom: 15px;\" id=\"_57694\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__57694\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_av-pro\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__57694\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields date special_fields has_prefix_icon\" style=\"margin-bottom: 15px;\" id=\"_34536\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__34536\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_gr_arrete\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__34536\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields date special_fields has_prefix_icon\" style=\"margin-bottom: 15px;\" id=\"_99791\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__99791\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Date<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><div class=\"input-group\" id=\"datetimepicker\" data-format=\"DD\/MM\/YYYY\" data-language=\"en\"><span class=\"input-group-addon prefix\" style=\"color: #888888; background: white; border-color: #dddddd;\"><span class=\"fa fa-calendar-o\" style=\"font-size: 17px;\"><\/span><\/span><input type=\"text\" name=\"date_accouchement\" class=\"error_message form-control the_input_element aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__99791\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_8607\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__8607\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Remarques<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"remarques\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__8607\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields divider divider html_fields\" style=\"margin-bottom: 15px;\" id=\"_74332\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><hr class=\"the_input_element\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_61219\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__61219\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Nouveau-n\u00e9<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"nouveau-n\u00e9\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__61219\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_78441\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__78441\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Terme<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"terme\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__78441\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-4 is_grid\" style=\"\" id=\"_76896\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_76896  col-sm-3 grid-target-0\" data-grid-width=\"3\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_62633\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__62633\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Apgar<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"apgar\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__62633\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_76896  col-sm-3 grid-target-1\" data-grid-width=\"3\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_37784\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__37784\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Poids \u00e0 la naissance<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"poids_\u00e0_la_naissance\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__37784\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_76896  col-sm-3 grid-target-2\" data-grid-width=\"3\" data-grid-num=\"2\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_22189\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__22189\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Taille \u00e0 la naissance<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"taille_\u00e0_la_naissance\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__22189\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_76896  col-sm-3 grid-target-3\" data-grid-width=\"3\" data-grid-num=\"3\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px; left: 0px;\" id=\"_14613\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__14613\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">P\u00e9rim\u00e8tre cr\u00e2nien<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"p\u00e9rim\u00e8tre_cr\u00e2nien\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__14613\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_66723\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__66723\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">D\u00e9veloppement psychomoteur<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"d\u00e9veloppement_psychomoteur\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__66723\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><div class=\"grid-system-2 is_grid\" style=\"\" id=\"_76575\"><div class=\"row grid_row\"><div class=\"grid_input_holder id-_76575  col-sm-6 grid-target-0\" data-grid-width=\"6\" data-grid-num=\"0\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px;\" id=\"_65901\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__65901\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Age de la marche <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"age_de_la_marche_\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__65901\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"grid_input_holder id-_76575  col-sm-6 grid-target-1\" data-grid-width=\"6\" data-grid-num=\"1\"><div class=\"form_field all_fields text common_fields\" style=\"margin-bottom: 15px; position: relative; top: 0px;\" id=\"_61002\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__61002\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Age de la parole<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><input type=\"text\" name=\"age_de_la_parole\" class=\"form-control error_message the_input_element aling_left align_left\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" data-secondary-message=\"\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__61002\" autocomplete=\"enabled\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields radio-group common_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_7368\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">D\u00e9ficit psychomoteur<\/span><\/label><\/div><div class=\"input_holder radio-group no-pre-suffix\"><div class=\"col-sm-12 the-radios input_container error_message\" id=\"the-radios\" data-checked-color=\"\" data-checked-class=\"fa-circle\" data-unchecked-class=\"\" data-placement=\"bottom\" data-content=\"Required\" title=\"\"><label class=\"radio-inline \" for=\"__45__7368_d\u00e9ficit_psychomoteur_Oui_oui\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"d\u00e9ficit_psychomoteur\" id=\"__45__7368_d\u00e9ficit_psychomoteur_Oui_oui\" value=\"Oui\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Oui<\/span><\/span><\/label><label class=\"radio-inline \" for=\"__45__7368_d\u00e9ficit_psychomoteur_Non_non\"><span class=\"has-pretty-child\"><div class=\"clearfix prettyradio labelright blue has-pretty-child\"><input class=\"radio the_input_element\" type=\"radio\" name=\"d\u00e9ficit_psychomoteur\" id=\"__45__7368_d\u00e9ficit_psychomoteur_Non_non\" value=\"Non\" style=\"display: none;\" autocomplete=\"enabled\"><a class=\"fa ui-state-default\" rel=\"nofollow\" href=\"#\">.<\/a><\/div><span class=\"input-label radio-label\">Non<\/span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_62536\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__62536\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Si oui pr\u00e9ciser<\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"si_oui_pr\u00e9ciser\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__62536\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields textarea common_fields\" style=\"margin-bottom: 15px;\" id=\"_33852\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 label_container align_left\"><label class=\"nf_title \" for=\"input__33852\"><span class=\"the_label\" style=\"font-size: 13px; color: #5b5b5b;\">Si malformations pr\u00e9ciser les d\u00e9tails (explorations) <\/span><\/label><\/div><div class=\"col-sm-12  input_container\"><textarea name=\"si_malformations_pr\u00e9ciser_les_d\u00e9tails_explorations_\" placeholder=\"\" data-maxlength-color=\"label label-success\" data-maxlength-position=\"bottom\" data-maxlength-show=\"false\" data-default-value=\"\" class=\"error_message the_input_element textarea pre-format form-control aling_left align_left\" data-onfocus-color=\"#66AFE9\" data-drop-focus-swadow=\"1\" data-placement=\"bottom\" data-content=\"Required\" title=\"\" style=\"font-size: 12px; color: #5b5b5b; background: white; border-color: #dddddd;\" id=\"input__33852\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"form_field all_fields submit-button submit-button the_submit button_fields common_fields preset_fields special_fields selection_fields\" style=\"margin-bottom: 15px;\" id=\"_50660\"><div class=\"row\"><div class=\"col-sm-12\" id=\"field_container\"><div class=\"row\"><div class=\"col-sm-12 input_container\"><button class=\"nex-submit svg_ready the_input_element btn btn-default\" data-ga=\"\">Envoyer<\/button><\/div><\/div><\/div><\/div><\/div><div style=\"clear:both;\"><\/div><\/form><\/div><\/div><style type=\"text\/css\" class=\"nex-forms-custom-css\"><\/style><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-443","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/pages\/443","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/comments?post=443"}],"version-history":[{"count":2,"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/pages\/443\/revisions"}],"predecessor-version":[{"id":1332,"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/pages\/443\/revisions\/1332"}],"wp:attachment":[{"href":"https:\/\/galpharma.tn\/en\/wp-json\/wp\/v2\/media?parent=443"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}