{"id":53349,"date":"2025-05-29T11:29:37","date_gmt":"2025-05-29T15:29:37","guid":{"rendered":"https:\/\/www.hancockhealth.org\/?page_id=53349"},"modified":"2025-05-30T10:21:08","modified_gmt":"2025-05-30T14:21:08","slug":"direct-to-consumer-healthcare-survey","status":"publish","type":"page","link":"https:\/\/hancockhealth.apgar.digital\/ja\/direct-to-consumer-healthcare-survey\/","title":{"rendered":"Direct To Consumer Healthcare Survey"},"content":{"rendered":"<div class=\"container mx-auto   wordpress-block wordpress-dable\/simple-form core-simple-form\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_68_container\" data-token=\"c89ae86c450021ac40eeacffb57ccf7b\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_dpc-to-members-survey\" data-token=\"c89ae86c450021ac40eeacffb57ccf7b\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">DPC to Members Survey<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"68\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_68\" id=\"frm_hide_fields_68\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"dpc-to-members-survey\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_68\" name=\"frm_submit_entry_68\" value=\"19f4005631\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ja\/wp-json\/wp\/v2\/pages\/53349\" \/><div id=\"frm_field_1305_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3 class=\"h2 han-barlow-xbold\">We appreciate your participation in this brief survey:<\/h3>\n<\/div>\n<div id=\"frm_field_1287_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_zf57e\" id=\"field_zf57e_label\" class=\"frm_primary_label\">Zip Code in Which You Reside\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"number\" id=\"field_zf57e\" name=\"item_meta[1287]\" value=\"\" data-invmsg=\"Zip Code in Which You Reside is invalid\" aria-invalid=\"false\"   min=\"0\" max=\"9999999\" step=\"any\" \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1346_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\n\t<div  id=\"field_7n2jl_label\" class=\"frm_primary_label\">Your Current Age\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_7n2jl_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-0\">\t\t\t<label  for=\"field_7n2jl-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-0\" value=\"18-26\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> 18-26<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-2\">\t\t\t<label  for=\"field_7n2jl-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-2\" value=\"36-45\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> 36-45<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-1\">\t\t\t<label  for=\"field_7n2jl-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-1\" value=\"27-35\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> 27-35<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-4\">\t\t\t<label  for=\"field_7n2jl-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-4\" value=\"56-65\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> 56-65<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-3\">\t\t\t<label  for=\"field_7n2jl-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-3\" value=\"46-55\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> 46-55<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1346-5\">\t\t\t<label  for=\"field_7n2jl-5\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1346]\" id=\"field_7n2jl-5\" value=\"Over 65\"\n\t\t data-invmsg=\"Your Current Age is invalid\"   \/> Over 65<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_1352_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\n\t<div  id=\"field_g67w_label\" class=\"frm_primary_label\">Number of People Living in Your Household\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_g67w_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-0\">\t\t\t<label  for=\"field_g67w-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-0\" value=\"1\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 1<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-3\">\t\t\t<label  for=\"field_g67w-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-3\" value=\"4\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 4<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-1\">\t\t\t<label  for=\"field_g67w-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-1\" value=\"2\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 2<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-4\">\t\t\t<label  for=\"field_g67w-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-4\" value=\"5\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 5<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-2\">\t\t\t<label  for=\"field_g67w-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-2\" value=\"3\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 3<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1352-5\">\t\t\t<label  for=\"field_g67w-5\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1352]\" id=\"field_g67w-5\" value=\"6 or more\"\n\t\t data-invmsg=\"Number of People Living in Your Household is invalid\"   \/> 6 or more<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_1290_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\r\n\t<div  id=\"field_czn42_label\" class=\"frm_primary_label\">Highest Level of Education Obtained (Choose One)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_czn42_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1290-0\">\t\t\t<label  for=\"field_czn42-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1290]\" id=\"field_czn42-0\" value=\"High School Degree\"\n\t\t data-invmsg=\"Highest Level of Education Obtained (Choose One) is invalid\"   \/> High School Degree<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1290-2\">\t\t\t<label  for=\"field_czn42-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1290]\" id=\"field_czn42-2\" value=\"Graduate Degree\"\n\t\t data-invmsg=\"Highest Level of Education Obtained (Choose One) is invalid\"   \/> Graduate Degree<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1290-1\">\t\t\t<label  for=\"field_czn42-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1290]\" id=\"field_czn42-1\" value=\"College Degree\"\n\t\t data-invmsg=\"Highest Level of Education Obtained (Choose One) is invalid\"   \/> College Degree<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1290-3\">\t\t\t<label  for=\"field_czn42-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1290]\" id=\"field_czn42-3\" value=\"Other (Professional Certifications)\"\n\t\t data-invmsg=\"Highest Level of Education Obtained (Choose One) is invalid\"   \/> Other (Professional Certifications)<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1348_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\"><\/h3>\n\n\n<\/div>\n<div id=\"frm_field_1295_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>Please provide insight into your current healthcare engagement:<\/h5>\n<\/div>\n<div id=\"frm_field_1283_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\r\n\t<div  id=\"field_ujrq2_label\" class=\"frm_primary_label\">Do you care more about you and your family\u2019s health more now than you did a year ago?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ujrq2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1283-0\">\t\t\t<label  for=\"field_ujrq2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1283]\" id=\"field_ujrq2-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you care more about you and your family\u2019s health more now than you did a year ago? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1283-2\">\t\t\t<label  for=\"field_ujrq2-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1283]\" id=\"field_ujrq2-2\" value=\"Same\"\n\t\t data-invmsg=\"Do you care more about you and your family\u2019s health more now than you did a year ago? is invalid\"   \/> Same<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1283-1\">\t\t\t<label  for=\"field_ujrq2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1283]\" id=\"field_ujrq2-1\" value=\"No\"\n\t\t data-invmsg=\"Do you care more about you and your family\u2019s health more now than you did a year ago? is invalid\"   \/> No<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1283-3\">\t\t\t<label  for=\"field_ujrq2-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1283]\" id=\"field_ujrq2-3\" value=\"Unsure\"\n\t\t data-invmsg=\"Do you care more about you and your family\u2019s health more now than you did a year ago? is invalid\"   \/> Unsure<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1347_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\n\t<div  id=\"field_474oq_label\" class=\"frm_primary_label\">How much do you usually pay each month for healthcare related expenses?\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_474oq_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1347-0\">\t\t\t<label  for=\"field_474oq-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1347]\" id=\"field_474oq-0\" value=\"Less than $300\"\n\t\t data-invmsg=\"How much do you usually pay each month for healthcare related expenses? is invalid\"   \/> Less than $300<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1347-2\">\t\t\t<label  for=\"field_474oq-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1347]\" id=\"field_474oq-2\" value=\"$750-$1,000\"\n\t\t data-invmsg=\"How much do you usually pay each month for healthcare related expenses? is invalid\"   \/> $750-$1,000<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1347-1\">\t\t\t<label  for=\"field_474oq-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1347]\" id=\"field_474oq-1\" value=\"$300-$750\"\n\t\t data-invmsg=\"How much do you usually pay each month for healthcare related expenses? is invalid\"   \/> $300-$750<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1347-3\">\t\t\t<label  for=\"field_474oq-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1347]\" id=\"field_474oq-3\" value=\"Greater than $1,000\"\n\t\t data-invmsg=\"How much do you usually pay each month for healthcare related expenses? is invalid\"   \/> Greater than $1,000<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1347-4\">\t\t\t<label  for=\"field_474oq-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1347]\" id=\"field_474oq-4\" value=\"Not Sure\"\n\t\t data-invmsg=\"How much do you usually pay each month for healthcare related expenses? is invalid\"   \/> Not Sure<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_1369_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col frm_other_container\">\n\t<div  id=\"field_oulgx_label\" class=\"frm_primary_label\">Which healthcare system do you primarily utilize?\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_oulgx_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-0\">\t\t\t<label  for=\"field_oulgx-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-0\" value=\"Hancock Health\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> Hancock Health<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-1\">\t\t\t<label  for=\"field_oulgx-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-1\" value=\"Ascension St. Vincent\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> Ascension St. Vincent<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-2\">\t\t\t<label  for=\"field_oulgx-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-2\" value=\"Community Health\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> Community Health<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-3\">\t\t\t<label  for=\"field_oulgx-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-3\" value=\"IU Health\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> IU Health<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-4\">\t\t\t<label  for=\"field_oulgx-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-4\" value=\"Franciscan Health\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> Franciscan Health<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1369-other_5\">\t\t\t<label  for=\"field_oulgx-other_5\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1369]\" id=\"field_oulgx-other_5\" value=\"Other\"\n\t\t data-invmsg=\"Which healthcare system do you primarily utilize? is invalid\"   \/> Other<\/label><label for=\"field_oulgx-other_5-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_oulgx-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][1369]\" value=\"\" \/><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_1297_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\r\n\t<div  id=\"field_xbdb0_label\" class=\"frm_primary_label\">How happy are you with your healthcare experiences based on what you need right now?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_xbdb0_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1297-0\">\t\t\t<label  for=\"field_xbdb0-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1297]\" id=\"field_xbdb0-0\" value=\"Very Satisfied\"\n\t\t data-invmsg=\"How happy are you with your healthcare experiences based on what you need right now? is invalid\"   \/> Very Satisfied<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1297-4\">\t\t\t<label  for=\"field_xbdb0-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1297]\" id=\"field_xbdb0-4\" value=\"Very Dissatisfied\"\n\t\t data-invmsg=\"How happy are you with your healthcare experiences based on what you need right now? is invalid\"   \/> Very Dissatisfied<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1297-1\">\t\t\t<label  for=\"field_xbdb0-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1297]\" id=\"field_xbdb0-1\" value=\"Satisfied\"\n\t\t data-invmsg=\"How happy are you with your healthcare experiences based on what you need right now? is invalid\"   \/> Satisfied<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1297-3\">\t\t\t<label  for=\"field_xbdb0-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1297]\" id=\"field_xbdb0-3\" value=\"Dissatisfied\"\n\t\t data-invmsg=\"How happy are you with your healthcare experiences based on what you need right now? is invalid\"   \/> Dissatisfied<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1297-2\">\t\t\t<label  for=\"field_xbdb0-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1297]\" id=\"field_xbdb0-2\" value=\"Neither Satisfied or Dissatisfied\"\n\t\t data-invmsg=\"How happy are you with your healthcare experiences based on what you need right now? is invalid\"   \/> Neither Satisfied or Dissatisfied<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1298_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col frm_other_container\">\r\n\t<div  id=\"field_hlvsp_label\" class=\"frm_primary_label\">What is the MOST important thing you look for when picking your healthcare options?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_hlvsp_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-0\">\t\t\t<label  for=\"field_hlvsp-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-0\" value=\"Quality\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Quality<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-1\">\t\t\t<label  for=\"field_hlvsp-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-1\" value=\"Availability\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Availability<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-2\">\t\t\t<label  for=\"field_hlvsp-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-2\" value=\"Proximity\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Proximity<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-3\">\t\t\t<label  for=\"field_hlvsp-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-3\" value=\"Cost of Care\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Cost of Care<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-4\">\t\t\t<label  for=\"field_hlvsp-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-4\" value=\"Options for Care\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Options for Care<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1298-other_6\">\t\t\t<label  for=\"field_hlvsp-other_6\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1298]\" id=\"field_hlvsp-other_6\" value=\"Other\"\n\t\t data-invmsg=\"What is the MOST important thing you look for when picking your healthcare options? is invalid\"   \/> Other<\/label><label for=\"field_hlvsp-other_6-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_hlvsp-other_6-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][1298]\" value=\"\" \/><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1350_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\"><\/h3>\n\n\n<\/div>\n<div id=\"frm_field_1299_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>These questions are related to direct to consumer (DTC) healthcare.<\/h5>\n<p><span data-olk-copy-source=\"MessageBody\">These questions focus on direct-to-consumer (DTC) healthcare. DTC provides primary healthcare services directly to consumers for a flat monthly fee. This model eliminates the need for insurance, copays, deductibles, or claims for the services rendered. Only those who pay the monthly fee can access these services. Patients benefit from immediate access to medical and wellness care without facing wait times, needing referrals, or navigating insurance networks. <em>It does not replace traditional insurance.\u00a0<\/em><\/span><\/p>\n<\/div>\n<div id=\"frm_field_1300_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_394z3\" id=\"field_394z3_label\" class=\"frm_primary_label\">If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_394z3_label\" role=\"group\"><div class=\"frm-star-group\">\n\t\t<input type=\"radio\" name=\"item_meta[1300]\" id=\"field_394z3-0\" value=\"1\"  data-invmsg=\"If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee? \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"   \/><label  for=\"field_394z3-0\" class=\"star-rating\">\n\t\t\t\t<svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><g clip-path=\"url(#frm-star-clip-path)\"><path fill=\"#EAECF0\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/><\/g><defs><clipPath id=\"frm-star-clip-path\"><path fill=\"#fff\" d=\"M0 0h20v20H0z\"\/><\/clipPath><\/defs>\n<\/svg><svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><path fill=\"#FDB022\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/>\n<\/svg>\t\t\t\t<span class=\"frm_screen_reader\">1 \u661f<\/span>\n\t\t\t<\/label>\n\t\t<input type=\"radio\" name=\"item_meta[1300]\" id=\"field_394z3-1\" value=\"2\"  data-invmsg=\"If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee? \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"   \/><label  for=\"field_394z3-1\" class=\"star-rating\">\n\t\t\t\t<svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><g clip-path=\"url(#frm-star-clip-path)\"><path fill=\"#EAECF0\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/><\/g><defs><clipPath id=\"frm-star-clip-path\"><path fill=\"#fff\" d=\"M0 0h20v20H0z\"\/><\/clipPath><\/defs>\n<\/svg><svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><path fill=\"#FDB022\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/>\n<\/svg>\t\t\t\t<span class=\"frm_screen_reader\">2 \u661f<\/span>\n\t\t\t<\/label>\n\t\t<input type=\"radio\" name=\"item_meta[1300]\" id=\"field_394z3-2\" value=\"3\"  data-invmsg=\"If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee? \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"   \/><label  for=\"field_394z3-2\" class=\"star-rating\">\n\t\t\t\t<svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><g clip-path=\"url(#frm-star-clip-path)\"><path fill=\"#EAECF0\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/><\/g><defs><clipPath id=\"frm-star-clip-path\"><path fill=\"#fff\" d=\"M0 0h20v20H0z\"\/><\/clipPath><\/defs>\n<\/svg><svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><path fill=\"#FDB022\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/>\n<\/svg>\t\t\t\t<span class=\"frm_screen_reader\">3 \u661f<\/span>\n\t\t\t<\/label>\n\t\t<input type=\"radio\" name=\"item_meta[1300]\" id=\"field_394z3-3\" value=\"4\"  data-invmsg=\"If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee? \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"   \/><label  for=\"field_394z3-3\" class=\"star-rating\">\n\t\t\t\t<svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><g clip-path=\"url(#frm-star-clip-path)\"><path fill=\"#EAECF0\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/><\/g><defs><clipPath id=\"frm-star-clip-path\"><path fill=\"#fff\" d=\"M0 0h20v20H0z\"\/><\/clipPath><\/defs>\n<\/svg><svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><path fill=\"#FDB022\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/>\n<\/svg>\t\t\t\t<span class=\"frm_screen_reader\">4 \u661f<\/span>\n\t\t\t<\/label>\n\t\t<input type=\"radio\" name=\"item_meta[1300]\" id=\"field_394z3-4\" value=\"5\"  data-invmsg=\"If direct-to-consumer healthcare options were available in your community, how interested would you be in utilizing the services for a monthly flat fee? \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"   \/><label  for=\"field_394z3-4\" class=\"star-rating\">\n\t\t\t\t<svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><g clip-path=\"url(#frm-star-clip-path)\"><path fill=\"#EAECF0\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/><\/g><defs><clipPath id=\"frm-star-clip-path\"><path fill=\"#fff\" d=\"M0 0h20v20H0z\"\/><\/clipPath><\/defs>\n<\/svg><svg  viewBox=\"0 0 20 20\" class=\"frmsvg\"><path fill=\"#FDB022\" d=\"m10 .5 2.64 6.36 6.87.55-5.23 4.48 1.6 6.7L10 15l-5.88 3.59 1.6-6.7L.49 7.41l6.86-.55L10 .5Z\"\/>\n<\/svg>\t\t\t\t<span class=\"frm_screen_reader\">5 \u661f<\/span>\n\t\t\t<\/label>\n<div style=\"clear:both;\"><\/div>\n<\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1296_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col frm_other_container\">\r\n\t<div  id=\"field_eokud_label\" class=\"frm_primary_label\">Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_eokud_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-0\">\t\t\t<label  for=\"field_eokud-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-0\" value=\"Fitness Facilities and Amenities\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Fitness Facilities and Amenities<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-8\">\t\t\t<label  for=\"field_eokud-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-8\" value=\"HydroMassage\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> HydroMassage<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-1\">\t\t\t<label  for=\"field_eokud-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-1\" value=\"Physical Therapy\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Physical Therapy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-7\">\t\t\t<label  for=\"field_eokud-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-7\" value=\"Nutritional Counseling\/Dietitian\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Nutritional Counseling\/Dietitian<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-2\">\t\t\t<label  for=\"field_eokud-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-2\" value=\"Primary Care Clinic\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Primary Care Clinic<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-4\">\t\t\t<label  for=\"field_eokud-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-4\" value=\"Med Spa (Facials, Cosmetic Injections, Etc)\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Med Spa (Facials, Cosmetic Injections, Etc)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-3\">\t\t\t<label  for=\"field_eokud-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-3\" value=\"Labs\/Imaging\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Labs\/Imaging<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-15\">\t\t\t<label  for=\"field_eokud-15\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-15\" value=\"Meal Prep Teaching Kitchen\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Meal Prep Teaching Kitchen<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-10\">\t\t\t<label  for=\"field_eokud-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-10\" value=\"Golf Simulator\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Golf Simulator<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-11\">\t\t\t<label  for=\"field_eokud-11\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-11\" value=\"Cold Plunge\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Cold Plunge<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-12\">\t\t\t<label  for=\"field_eokud-12\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][]\" id=\"field_eokud-12\" value=\"Childcare watch during visits\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Childcare watch during visits<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1296-other_14\">\t\t\t<label  for=\"field_eokud-other_14\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[1296][other_14]\" id=\"field_eokud-other_14\" value=\"Other\"  data-invmsg=\"Here are the services and offerings that could be included in a DTC healthcare package. Which services are you most likely to use? is invalid\"   \/> Other<\/label><label for=\"field_eokud-other_14-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_eokud-other_14-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][1296][other_14]\" value=\"\" \/><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1353_container\" class=\"frm_form_field form-field  frm_top_container frm_two_col\">\n\t<div  id=\"field_ashf7_label\" class=\"frm_primary_label\">How much would you be willing to pay monthly for unlimited use of all these services for everyone in your household? * Includes your wellness membership\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/div>\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ashf7_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1353-3\">\t\t\t<label  for=\"field_ashf7-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1353]\" id=\"field_ashf7-3\" value=\"$300-$375\"\n\t\t data-invmsg=\"How much would you be willing to pay monthly for unlimited use of all these services for everyone in your household? * Includes your wellness membership is invalid\"   \/> $300-$375<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1353-1\">\t\t\t<label  for=\"field_ashf7-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1353]\" id=\"field_ashf7-1\" value=\"$150-$225\"\n\t\t data-invmsg=\"How much would you be willing to pay monthly for unlimited use of all these services for everyone in your household? * Includes your wellness membership is invalid\"   \/> $150-$225<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1353-2\">\t\t\t<label  for=\"field_ashf7-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1353]\" id=\"field_ashf7-2\" value=\"$225-$300\"\n\t\t data-invmsg=\"How much would you be willing to pay monthly for unlimited use of all these services for everyone in your household? * Includes your wellness membership is invalid\"   \/> $225-$300<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1353-0\">\t\t\t<label  for=\"field_ashf7-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1353]\" id=\"field_ashf7-0\" value=\"Not Interested\"\n\t\t data-invmsg=\"How much would you be willing to pay monthly for unlimited use of all these services for everyone in your household? * Includes your wellness membership is invalid\"   \/> Not Interested<\/label><\/div>\n<\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_1302_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first vertical_radio\">\r\n\t<div  id=\"field_dho3s_label\" class=\"frm_primary_label\">Would you be interested in joining a community focus group to explore potential direct-to-consumer healthcare options in the area?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_dho3s_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1302-0\">\t\t\t<label  for=\"field_dho3s-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1302]\" id=\"field_dho3s-0\" value=\"Yes\"\n\t\t data-invmsg=\"Would you be interested in joining a community focus group to explore potential direct-to-consumer healthcare options in the area? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1302-1\">\t\t\t<label  for=\"field_dho3s-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[1302]\" id=\"field_dho3s-1\" value=\"No\"\n\t\t data-invmsg=\"Would you be interested in joining a community focus group to explore potential direct-to-consumer healthcare options in the area? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1303_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<div  id=\"field_i9uvg_label\" class=\"frm_primary_label\">If so, please provide your contact information:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_i9uvg_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tIf so, please provide your contact information:\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_1303\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1303-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_i9uvg_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_i9uvg_first\" value=\"\" name=\"item_meta[1303][first]\" autocomplete=\"given-name\" data-invmsg=\"If so, please provide your contact information: \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1303_first_desc\">First Name<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_1303-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_i9uvg_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast Name\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_i9uvg_last\" value=\"\" name=\"item_meta[1303][last]\" autocomplete=\"family-name\" data-invmsg=\"If so, please provide your contact information: \u306f\u7121\u52b9\u3067\u3059\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_1303_last_desc\">Last Name<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1304_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_4cnsb\" id=\"field_4cnsb_label\" class=\"frm_primary_label\">Email\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_4cnsb\" name=\"item_meta[1304]\" value=\"\"  autocomplete=\"email\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_1282_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_1734_container\">\n\t\t\t<label for=\"field_19oo7\" >\n\t\t\t\t\u3042\u306a\u305f\u304c\u4eba\u9593\u306e\u5834\u5408\u3001\u3053\u306e\u30d5\u30a3\u30fc\u30eb\u30c9\u306f\u7a7a\u767d\u306e\u307e\u307e\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002\t\t\t<\/label>\n\t\t\t<input  id=\"field_19oo7\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[1734]\" value=\"\"  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