{"id":6868,"date":"2025-11-21T09:18:17","date_gmt":"2025-11-21T14:18:17","guid":{"rendered":"https:\/\/periproxy.com\/?page_id=6868"},"modified":"2026-05-20T13:43:19","modified_gmt":"2026-05-20T17:43:19","slug":"minirqlq","status":"publish","type":"page","link":"https:\/\/periproxy.com\/en\/minirqlq\/","title":{"rendered":"miniRQLQ &#8211; MAPI"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6868\" class=\"elementor elementor-6868\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5a5387a2 elementor-section-height-min-height elementor-section-stretched elementor-section-content-top elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"5a5387a2\" data-element_type=\"section\" data-e-type=\"section\" 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data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;f188bea&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div 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indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_266' id='gform_266'  action='\/en\/wp-json\/wp\/v2\/pages\/6868#gf_266' data-formid='266' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfcVEokAAAAAGEsyVCmhFv4Q0tMXTKXOqoeR97w' data-tabindex='0'><input id=\"input_d90781cf3fc7c1317a000fd560abe01f\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_d90781cf3fc7c1317a000fd560abe01f\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_266_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_266' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_155\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/br>\n<\/br>\n<h3 style=\"text-align: center\";>MINI-QUESTIONNAIRE SUR LA QUALIT\u00c9 DE VIE LI\u00c9E \u00c0 LA RHINOCONJONCTIVITE (MiniRQLQ)<\/h3><\/br>\n<h4 style=\"text-align: center\";><b>QUESTIONNAIRE AUTO-ADMINISTR\u00c9 (SELF-ADMINISTERED)<\/h4><\/b><h4 style=\"text-align: center\";><b>CANADIAN FRENCH VERSION<\/h4><\/b><\/br><\/br>\n<div style=\"text-align: center;\">\n  <img decoding=\"async\" src=\"https:\/\/periproxy.com\/wp-content\/uploads\/2026\/04\/QoL-Tech-logo.png\" alt=\"\" \/>\n<\/div><\/div><div id=\"field_266_156\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_top no_margin_bottom gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/br>\n<\/br>\n<\/br>\n<\/br>\n<P style=\"font-family: Arial; font-size: 12px; color: #1D2341; text-align: left; margin: 0 0 5px 0; line-height: 1.15\">\u00a9 Le Mini-questionnaire sur la qualit\u00e9 de vie li\u00e9e \u00e0 la Rhinoconjonctivite (MiniRQLQ) est prot\u00e9g\u00e9 par un droit d\u2019auteur. Il ne peut \u00eatre modifi\u00e9, vendu (sous forme imprim\u00e9e ou \u00e9lectronique), traduit ni adapt\u00e9 sans la permission d\u2019Elizabeth Juniper au nom de QOL Technologies Limited.<\/p>\n<\/br>\n<\/br>\n<\/br>\n<\/br>\n<P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_266_295' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_2' class='gform_page no_margin_top' data-js='page-field-id-295' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nVeuillez r\u00e9pondre \u00e0 <b>toutes<\/b> les questions en choisissant le chiffre qui d\u00e9crit le mieux \u00e0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux.<\/b><\/h5><\/div><div id=\"field_266_375\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/br>\n<\/br>\n<P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_335' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_335' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_3' class='gform_page no_margin_top' data-js='page-field-id-335' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_235\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">ACTIVIT\u00c9S<\/h4><\/div><div id=\"field_266_321\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n\u00c0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux<\/b>?<\/h5><\/br><\/div><div id=\"field_266_337\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n1. ACTIVIT\u00c9S HABITUELLES \u00c0 LA MAISON ET AU TRAVAIL<\/br>(votre emploi ou les t\u00e2ches que vous devez faire r\u00e9guli\u00e8rement chez vous et\/ou dans votre jardin)<\/h5><\/br><\/div><fieldset id=\"field_266_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_234'>\n\t\t\t<div class='gchoice gchoice_266_234_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_234_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_0' id='label_266_234_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_234_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_1' id='label_266_234_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_234_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_2' id='label_266_234_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_234_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_3' id='label_266_234_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_234_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_4' id='label_266_234_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_234_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_5' id='label_266_234_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_234_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_234_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_234_6' id='label_266_234_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_376\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_336' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_336' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_4' class='gform_page no_margin_top' data-js='page-field-id-336' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_343\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">ACTIVIT\u00c9S<\/h4><\/div><div id=\"field_266_340\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n\u00c0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux<\/b>?<\/h5><\/br><\/div><div id=\"field_266_322\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n2. ACTIVIT\u00c9S DE LOISIRS<\/br>(activit\u00e9s int\u00e9rieures et ext\u00e9rieures avec votre famille et vos amis, faire du sport, activit\u00e9s sociales, loisirs)<\/h5><\/br><\/div><fieldset id=\"field_266_298\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_298'>\n\t\t\t<div class='gchoice gchoice_266_298_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_298_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_0' id='label_266_298_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_298_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_1' id='label_266_298_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_298_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_2' id='label_266_298_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_298_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_3' id='label_266_298_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_298_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_4' id='label_266_298_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_298_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_5' id='label_266_298_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_298_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_298' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_298_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_298_6' id='label_266_298_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_377\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_361' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_361' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_5' class='gform_page no_margin_top' data-js='page-field-id-361' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_378\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">ACTIVIT\u00c9S<\/h4><\/div><div id=\"field_266_341\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n\u00c0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux<\/b>?<\/h5><\/br><\/div><div id=\"field_266_323\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n3. SOMMEIL<\/br>(difficult\u00e9s \u00e0 avoir une bonne nuit de sommeil et\/ou \u00e0 vous endormir la nuit)<\/h5><\/br><\/div><fieldset id=\"field_266_299\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_299'>\n\t\t\t<div class='gchoice gchoice_266_299_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_299_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_0' id='label_266_299_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_299_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_1' id='label_266_299_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_299_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_2' id='label_266_299_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_299_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_3' id='label_266_299_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_299_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_4' id='label_266_299_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_299_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_5' id='label_266_299_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_299_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_299_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_299_6' id='label_266_299_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_379\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_362' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_362' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_6' class='gform_page no_margin_top' data-js='page-field-id-362' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_301\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES G\u00c9N\u00c9RAUX<\/h4><\/div><div id=\"field_266_344\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n\u00c0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux<\/b>?<\/h5><\/br><\/div><div id=\"field_266_324\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n4. BESOIN DE VOUS FROTTER LE NEZ OU LES YEUX<\/h5><\/br><\/div><fieldset id=\"field_266_300\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_300'>\n\t\t\t<div class='gchoice gchoice_266_300_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_300_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_0' id='label_266_300_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_300_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_1' id='label_266_300_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_300_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_2' id='label_266_300_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_300_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_3' id='label_266_300_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_300_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_4' id='label_266_300_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_300_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_5' id='label_266_300_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_300_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_300_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_300_6' id='label_266_300_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_380\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_363' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_363' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_7' class='gform_page no_margin_top' data-js='page-field-id-363' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_346\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES G\u00c9N\u00c9RAUX<\/h4><\/div><div id=\"field_266_345\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n\u00c0 quel point vous avez \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> au cours de la <b>derni\u00e8re semaine \u00e0 cause de vos probl\u00e8mes de nez\/d\u2019yeux<\/b>?<\/h5><\/br><\/div><div id=\"field_266_325\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n5. BESOIN DE VOUS MOUCHER CONTINUELLEMENT<\/h5><\/br><\/div><fieldset id=\"field_266_302\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_302'>\n\t\t\t<div class='gchoice gchoice_266_302_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_302_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_0' id='label_266_302_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_302_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_1' id='label_266_302_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_302_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_2' id='label_266_302_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_302_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_3' id='label_266_302_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_302_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_4' id='label_266_302_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_302_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_5' id='label_266_302_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_302_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_302' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_302_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_302_6' id='label_266_302_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_381\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_364' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_364' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_8' class='gform_page no_margin_top' data-js='page-field-id-364' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_8' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_307\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES DE NEZ<\/h4><\/div><div id=\"field_266_306\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_326\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n6. \u00c9TERNUEMENTS<\/h5><\/br><\/div><fieldset id=\"field_266_304\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_304'>\n\t\t\t<div class='gchoice gchoice_266_304_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_304_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_0' id='label_266_304_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_304_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_1' id='label_266_304_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_304_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_2' id='label_266_304_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_304_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_3' id='label_266_304_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_304_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_4' id='label_266_304_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_304_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_5' id='label_266_304_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_304_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_304_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_304_6' id='label_266_304_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_382\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_365' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_365' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_9' class='gform_page no_margin_top' data-js='page-field-id-365' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_9' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_347\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES DE NEZ<\/h4><\/div><div id=\"field_266_348\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_327\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n7. NEZ CONGESTIONN\u00c9\/NEZ BOUCH\u00c9<\/h5><\/br><\/div><fieldset id=\"field_266_309\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_309'>\n\t\t\t<div class='gchoice gchoice_266_309_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_309_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_0' id='label_266_309_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_309_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_1' id='label_266_309_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_309_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_2' id='label_266_309_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_309_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_3' id='label_266_309_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_309_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_4' id='label_266_309_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_309_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_5' id='label_266_309_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_309_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_309' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_309_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_309_6' id='label_266_309_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_383\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_366' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_366' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_10' class='gform_page no_margin_top' data-js='page-field-id-366' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_10' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_349\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES DE NEZ<\/h4><\/div><div id=\"field_266_350\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_328\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n8. NEZ QUI COULE<\/h5><\/br><\/div><fieldset id=\"field_266_311\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_311'>\n\t\t\t<div class='gchoice gchoice_266_311_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_311_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_0' id='label_266_311_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_311_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_1' id='label_266_311_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_311_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_2' id='label_266_311_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_311_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_3' id='label_266_311_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_311_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_4' id='label_266_311_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_311_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_5' id='label_266_311_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_311_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_311_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_311_6' id='label_266_311_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_384\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_367' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_367' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_11' class='gform_page no_margin_top' data-js='page-field-id-367' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_11' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_313\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES D\u2019YEUX<\/h4><\/div><div id=\"field_266_351\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_329\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n9. YEUX QUI PIQUENT<\/h5><\/br><\/div><fieldset id=\"field_266_312\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_312'>\n\t\t\t<div class='gchoice gchoice_266_312_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_312_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_0' id='label_266_312_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_312_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_1' id='label_266_312_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_312_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_2' id='label_266_312_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_312_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_3' id='label_266_312_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_312_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_4' id='label_266_312_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_312_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_5' id='label_266_312_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_312_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_312_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_312_6' id='label_266_312_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_385\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_368' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_368' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_12' class='gform_page no_margin_top' data-js='page-field-id-368' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_12' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_352\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES D\u2019YEUX<\/h4><\/div><div id=\"field_266_353\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_330\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n10. YEUX DOULOUREUX<\/h5><\/br><\/div><fieldset id=\"field_266_314\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_314'>\n\t\t\t<div class='gchoice gchoice_266_314_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_314_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_0' id='label_266_314_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_314_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_1' id='label_266_314_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_314_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_2' id='label_266_314_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_314_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_3' id='label_266_314_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_314_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_4' id='label_266_314_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_314_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_5' id='label_266_314_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_314_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_314_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_314_6' id='label_266_314_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_386\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_369' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_369' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_13' class='gform_page no_margin_top' data-js='page-field-id-369' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_13' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_354\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">PROBL\u00c8MES D\u2019YEUX<\/h4><\/div><div id=\"field_266_355\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\nAu cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_331\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n11. YEUX LARMOYANTS<\/h5><\/br><\/div><fieldset id=\"field_266_315\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_315'>\n\t\t\t<div class='gchoice gchoice_266_315_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_315_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_0' id='label_266_315_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_315_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_1' id='label_266_315_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_315_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_2' id='label_266_315_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_315_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_3' id='label_266_315_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_315_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_4' id='label_266_315_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_315_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_5' id='label_266_315_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_315_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_315' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_315_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_315_6' id='label_266_315_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_387\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_370' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_370' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_14' class='gform_page no_margin_top' data-js='page-field-id-370' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_14' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_316\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">AUTRES SYMPT\u00d4MES<\/h4><\/div><div id=\"field_266_356\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">Au cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_332\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n12. FATIGUE ET\/OU \u00c9PUISEMENT<\/h5><\/br><\/div><fieldset id=\"field_266_317\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_317'>\n\t\t\t<div class='gchoice gchoice_266_317_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_317_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_0' id='label_266_317_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_317_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_1' id='label_266_317_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_317_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_2' id='label_266_317_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_317_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_3' id='label_266_317_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_317_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_4' id='label_266_317_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_317_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_5' id='label_266_317_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_317_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_317' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_317_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_317_6' id='label_266_317_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_388\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_371' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_371' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_15' class='gform_page no_margin_top' data-js='page-field-id-371' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_15' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_359\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">AUTRES SYMPT\u00d4MES<\/h4><\/div><div id=\"field_266_358\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">Au cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_333\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n13. SOIF<\/h5><\/br><\/div><fieldset id=\"field_266_318\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_318'>\n\t\t\t<div class='gchoice gchoice_266_318_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_318_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_0' id='label_266_318_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_318_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_1' id='label_266_318_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_318_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_2' id='label_266_318_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_318_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_3' id='label_266_318_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_318_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_4' id='label_266_318_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_318_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_5' id='label_266_318_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_318_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_318_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_318_6' id='label_266_318_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_389\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_372' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_372' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_16' class='gform_page no_margin_top' data-js='page-field-id-372' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_16' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_357\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 style=\"text-align: left;font-weight:bold\">AUTRES SYMPT\u00d4MES<\/h4><\/div><div id=\"field_266_360\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">Au cours de la <b>derni\u00e8re semaine<\/b>, \u00e0 quel point avez-vous \u00e9t\u00e9 <b>incommod\u00e9(e)<\/b> par chacun des probl\u00e8mes suivants?<\/h5><\/br><\/div><div id=\"field_266_334\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h5 style=\"text-align: left; color: #1D2341; font-family:arial; font-weight:normal\">\n14. IRRITABILIT\u00c9<\/h5><\/br><\/div><fieldset id=\"field_266_319\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full no_number buttonized no_margin_top gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_266_319'>\n\t\t\t<div class='gchoice gchoice_266_319_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='0 - Pas du tout incommod\u00e9(e)'  id='choice_266_319_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_0' id='label_266_319_0' class='gform-field-label gform-field-label--type-inline'>0 - Pas du tout incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='1 - Presque pas incommod\u00e9(e)'  id='choice_266_319_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_1' id='label_266_319_1' class='gform-field-label gform-field-label--type-inline'>1 - Presque pas incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='2 - Un peu incommod\u00e9(e)'  id='choice_266_319_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_2' id='label_266_319_2' class='gform-field-label gform-field-label--type-inline'>2 - Un peu incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='3 - Moyennement incommod\u00e9(e)'  id='choice_266_319_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_3' id='label_266_319_3' class='gform-field-label gform-field-label--type-inline'>3 - Moyennement incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='4 - Pas mal incommod\u00e9(e)'  id='choice_266_319_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_4' id='label_266_319_4' class='gform-field-label gform-field-label--type-inline'>4 - Pas mal incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='5 - Tr\u00e8s incommod\u00e9(e)'  id='choice_266_319_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_5' id='label_266_319_5' class='gform-field-label gform-field-label--type-inline'>5 - Tr\u00e8s incommod\u00e9(e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_266_319_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_319' type='radio' value='6 - Extr\u00eamement incommod\u00e9(e)'  id='choice_266_319_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_266_319_6' id='label_266_319_6' class='gform-field-label gform-field-label--type-inline'>6 - Extr\u00eamement incommod\u00e9(e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_266_390\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><P style=\"font-family: Arial; font-size: 12px; text-align: left; margin: 0 0 5px 0; line-height: 1.15; color: #1D2341\">MiniRQLQ \u00a9 1997 QOL TECHNOLOGIES Ltd.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_266_374' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_266_374' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_266_17' class='gform_page no_margin_top' data-js='page-field-id-374' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_266_17' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_266_373\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no_number no_margin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p style=\"text-align: left;font-family:arial;color:#1D2341\">Vous avez r\u00e9pondu \u00e0 toutes les questions du questionnaire. \n<\/br>\nSi vous souhaitez revoir ou modifier vos r\u00e9ponses, appuyez sur \u00ab Retour \u00bb. Appuyez sur \u00ab Soumettre \u00bb si vous \u00eates pr\u00eat(e) \u00e0 enregistrer vos r\u00e9ponses.\n<\/p><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_266' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Retour'  \/> <input type='submit' id='gform_submit_button_266' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <input type='hidden' name='gform_ajax' value='form_id=266&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;hash=c1a148336593541251bfe63e78a10cb3' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_266' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' 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