{"id":4657,"date":"2026-03-08T00:39:06","date_gmt":"2026-03-07T23:39:06","guid":{"rendered":"https:\/\/blueportance.com\/?page_id=4657"},"modified":"2026-03-09T10:10:34","modified_gmt":"2026-03-09T09:10:34","slug":"contribuer","status":"publish","type":"page","link":"https:\/\/blueportance.com\/en\/reliance\/membres\/contribuer\/","title":{"rendered":""},"content":{"rendered":"\n<section class=\"bp-private-members\">\n\n  <!-- TITRE -->\n  <header class=\"bp-reliance-hero\">\n    <div class=\"bp-reliance-content\">\n      <div class=\"bp-reliance-text\">\n        <h1>Reliance<\/h1>\n        <h2 class=\"bp-reliance-subtitle\">\n          Partager une exp\u00e9rience\n        <\/h2>\n      <\/div>\n      <div class=\"bp-reliance-image\">\n        <img decoding=\"async\" src=\"http:\/\/blueportance.com\/wp-content\/uploads\/reliance-connexion-entre-personnes.png\" alt=\"Reliance \u2013 Connexion et partage entre personnes\">\n      <\/div>\n    <\/div>\n  <\/header>\n\n<!-- RAPPEL CADRE + MODE D\u2019EMPLOI -->\n<div class=\"bp-box bp-box--warning\">\n  <p>\n    <strong>Rappel :<\/strong> cet espace recueille des <strong>exp\u00e9riences v\u00e9cues positives<\/strong> et non prescriptives.\n    Il ne fournit ni diagnostic, ni conseil, ni recommandation m\u00e9dicale.\n  <\/p>\n  <p>\n    Votre contribution a pour but de rendre visible une exp\u00e9rience de soin, de prise en charge ou d\u2019adaptation ayant eu un effet positif dans votre parcours.\n  <\/p>\n  <p>\n    D\u00e9crivez chaque <strong>\u00e9pisode th\u00e9rapeutique significatif<\/strong> de votre parcours.\n    Un \u00e9pisode correspond \u00e0 une prise en charge pr\u00e9cise : un traitement, une intervention ou un suivi r\u00e9alis\u00e9 par un praticien ou une \u00e9quipe de soins.\n  <\/p>\n  <p style=\"margin-bottom:0;\">\n    Si vous avez eu plusieurs traitements ou plusieurs praticiens, cliquez sur\n    <strong>\u00ab Ajouter un \u00e9pisode th\u00e9rapeutique \u00bb<\/strong> et d\u00e9crivez-les s\u00e9par\u00e9ment.\n    Chaque contribution est <strong>relue et valid\u00e9e manuellement<\/strong> avant d\u2019\u00eatre int\u00e9gr\u00e9e \u00e0 la base commune.\n  <\/p>\n<\/div>\n  <!-- INTRO -->\n  <div class=\"bp-private-members__card\" style=\"margin-top:14px;\">\n    <h2>Votre contribution<\/h2>\n    <p>\n      Merci de d\u00e9crire de fa\u00e7on simple et concr\u00e8te l\u2019exp\u00e9rience que vous souhaitez partager :\n      pathologie ou contexte, douleurs concern\u00e9es, traitement ou approche adopt\u00e9e,\n      praticien ou structure, et effets positifs ressentis.\n    <\/p>\n    <p style=\"margin-bottom:0;\">\n      L\u2019objectif n\u2019est pas de publier un avis libre, mais de constituer une base d\u2019exp\u00e9riences structur\u00e9es,\n      utile pour mieux s\u2019orienter dans des parcours souvent complexes.\n    <\/p>\n  <\/div>\n\n  <!-- FORMULAIRE -->\n  <div class=\"bp-private-members__card\" style=\"margin-top:14px;\">\n    <h2>Formulaire de retour d\u2019exp\u00e9rience<\/h2>\n\n    <div class=\"bp-form-wrap\">\n      \t\t\t\t<form id=\"bp-reliance-rex-form\" class=\"acf-form\" action=\"\" method=\"post\">\n\t\t\t\t\t<div id=\"acf-form-data\" class=\"acf-hidden\">\n\t\t<input type=\"hidden\" id=\"_acf_screen\" name=\"_acf_screen\" value=\"acf_form\"\/><input type=\"hidden\" id=\"_acf_post_id\" name=\"_acf_post_id\" value=\"new_post\"\/><input type=\"hidden\" id=\"_acf_validation\" name=\"_acf_validation\" value=\"1\"\/><input type=\"hidden\" id=\"_acf_form\" name=\"_acf_form\" value=\"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\"\/><input type=\"hidden\" id=\"_acf_nonce\" name=\"_acf_nonce\" value=\"c75351dce2\"\/><input type=\"hidden\" id=\"_acf_changed\" name=\"_acf_changed\" value=\"0\"\/>\t<\/div>\n\t\t\t\t<div class=\"acf-fields acf-form-fields -top\">\n\t\t\t\t\t\t\t\t<div class=\"acf-field acf-field-message acf-field-698efebc31c14\" data-name=\"pathologie\" data-type=\"message\" data-key=\"field_698efebc31c14\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698efebc31c14\">1. PATHOLOGIE<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-698d9ba26eb20 is-required\" data-name=\"pathologie_principale\" data-type=\"radio\" data-key=\"field_698d9ba26eb20\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698d9ba26eb20-label\">Pathologie principale diagnostiqu\u00e9e <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698d9ba26eb20]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_698d9ba26eb20-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_698d9ba26eb20-coccygodynie\" name=\"acf[field_698d9ba26eb20]\" value=\"coccygodynie\" checked=\"checked\"\/>Coccygodynie<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-endometriose\" name=\"acf[field_698d9ba26eb20]\" value=\"endometriose\"\/>Endom\u00e9triose<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-fibromyalgie\" name=\"acf[field_698d9ba26eb20]\" value=\"fibromyalgie\"\/>Fibromyalgie<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-nevralgie_cluneale\" name=\"acf[field_698d9ba26eb20]\" value=\"nevralgie_cluneale\"\/>N\u00e9vralgie clun\u00e9ale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-nevralgie_pudendale\" name=\"acf[field_698d9ba26eb20]\" value=\"nevralgie_pudendale\"\/>N\u00e9vralgie pudendale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-lombalgie_chronique\" name=\"acf[field_698d9ba26eb20]\" value=\"lombalgie_chronique\"\/>Lombalgie chronique<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-syndrome-myofascial\" name=\"acf[field_698d9ba26eb20]\" value=\"syndrome-myofascial\"\/>Syndrome myofascial<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-autres_douleurs_perineales_chroniques\" name=\"acf[field_698d9ba26eb20]\" value=\"autres_douleurs_perineales_chroniques\"\/>Autres douleurs p\u00e9rin\u00e9ales chroniques<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-autre\" name=\"acf[field_698d9ba26eb20]\" value=\"autre\"\/>Autre pathologie diagnostiqu\u00e9e<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698d9ba26eb20-non_diagnostique\" name=\"acf[field_698d9ba26eb20]\" value=\"non_diagnostique\"\/>Aucune pathologie diagnostiqu\u00e9e<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad50c4a6b71\" data-name=\"traitement_adopte_autre_copier\" data-type=\"text\" data-key=\"field_69ad50c4a6b71\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d9ba26eb20&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ad50c4a6b71\">Si autre, pr\u00e9ciser : (copier)<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ad50c4a6b71\" name=\"acf[field_69ad50c4a6b71]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-698d9e7b6eb22\" data-name=\"pathologie_secondaire_diagnostiquee\" data-type=\"checkbox\" data-key=\"field_698d9e7b6eb22\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698d9e7b6eb22-label\">Pathologie secondaire diagnostiqu\u00e9e<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698d9e7b6eb22]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698d9e7b6eb22-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-coccygodynie\" name=\"acf[field_698d9e7b6eb22][]\" value=\"coccygodynie\"\/> Coccygodynie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-endometriose\" name=\"acf[field_698d9e7b6eb22][]\" value=\"endometriose\"\/> Endom\u00e9triose<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-fibromyalgie\" name=\"acf[field_698d9e7b6eb22][]\" value=\"fibromyalgie\"\/> Fibromyalgie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-nevralgie_cluneale\" name=\"acf[field_698d9e7b6eb22][]\" value=\"nevralgie_cluneale\"\/> N\u00e9vralgie clun\u00e9ale<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-nevralgie_pudendale\" name=\"acf[field_698d9e7b6eb22][]\" value=\"nevralgie_pudendale\"\/> N\u00e9vralgie pudendale<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-lombalgie_chronique\" name=\"acf[field_698d9e7b6eb22][]\" value=\"lombalgie_chronique\"\/> Lombalgie chronique<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-syndrome-myofascial\" name=\"acf[field_698d9e7b6eb22][]\" value=\"syndrome-myofascial\"\/> Syndrome myofascial<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-autres_douleurs_perineales_chroniques\" name=\"acf[field_698d9e7b6eb22][]\" value=\"autres_douleurs_perineales_chroniques\"\/> Autres douleurs p\u00e9rin\u00e9ales chroniques<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-autre\" name=\"acf[field_698d9e7b6eb22][]\" value=\"autre\"\/> Autre pathologie diagnostiqu\u00e9e<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698d9e7b6eb22-non_diagnostique\" name=\"acf[field_698d9e7b6eb22][]\" value=\"non_diagnostique\"\/> Aucune pathologie diagnostiqu\u00e9e<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d9da06eb21\" data-name=\"pathologie_principale_autre\" data-type=\"text\" data-key=\"field_698d9da06eb21\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698d9da06eb21\">Pr\u00e9cisez la pathologie principale<\/label><p class=\"description\">Vous pouvez pr\u00e9ciser ici tout \u00e9l\u00e9ment utile : diagnostic pos\u00e9 ou \u00e9voqu\u00e9, examens r\u00e9alis\u00e9s (IRM, scanner, radiographie\u2026), bloc test nerveux, infiltrations diagnostiques, ou tout autre \u00e9l\u00e9ment que vous jugez important.<\/p><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_698d9da06eb21\" name=\"acf[field_698d9da06eb21]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-698efedd31c15\" data-name=\"caracterisation_douleur\" data-type=\"message\" data-key=\"field_698efedd31c15\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698efedd31c15\">2. CARACTERISATION DE LA DOULEUR<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-group acf-field-698da0aac31c6\" data-name=\"localisation_douleur\" data-type=\"group\" data-key=\"field_698da0aac31c6\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698da0aac31c6\">Localisation(s) principale(s) des douleurs<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-fields -top -border\"><div class=\"acf-field acf-field-checkbox acf-field-69b08e24cb5e3\" data-name=\"douleurs_genitales_urinaires\" data-type=\"checkbox\" data-key=\"field_69b08e24cb5e3\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-label\">Douleurs g\u00e9nitales \/ urinaires<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-clitoris\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3][]\" value=\"clitoris\"\/> Clitoris<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-verge\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3][]\" value=\"verge\"\/> Verge<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-bourses\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3][]\" value=\"bourses\"\/> Bourses<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-levres\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3][]\" value=\"levres\"\/> L\u00e8vres (grandes\/petites)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e24cb5e3-uretre\" name=\"acf[field_698da0aac31c6][field_69b08e24cb5e3][]\" value=\"uretre\"\/> M\u00e9at urinaire \/ ur\u00e8tre<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69b08e25cb5e4\" data-name=\"douleurs_perineales_anales\" data-type=\"checkbox\" data-key=\"field_69b08e25cb5e4\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da0aac31c6-field_69b08e25cb5e4-label\">Douleurs p\u00e9rin\u00e9ales \/ anales<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da0aac31c6][field_69b08e25cb5e4]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698da0aac31c6-field_69b08e25cb5e4-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e25cb5e4-anus\" name=\"acf[field_698da0aac31c6][field_69b08e25cb5e4][]\" value=\"anus\"\/> Anus<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e25cb5e4-perinee\" name=\"acf[field_698da0aac31c6][field_69b08e25cb5e4][]\" value=\"perinee\"\/> P\u00e9rin\u00e9e (zone entre les organes g\u00e9nitaux et l\u2019anus)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08e25cb5e4-pli_interfessier\" name=\"acf[field_698da0aac31c6][field_69b08e25cb5e4][]\" value=\"pli_interfessier\"\/> Pli interfessier<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69b08f25cb5e5\" data-name=\"douleurs_pelviennes_posterieures\" data-type=\"checkbox\" data-key=\"field_69b08f25cb5e5\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da0aac31c6-field_69b08f25cb5e5-label\">Douleurs pelviennes post\u00e9rieures<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da0aac31c6][field_69b08f25cb5e5]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698da0aac31c6-field_69b08f25cb5e5-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f25cb5e5-coccyx\" name=\"acf[field_698da0aac31c6][field_69b08f25cb5e5][]\" value=\"coccyx\"\/> Coccyx<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f25cb5e5-sacrum\" name=\"acf[field_698da0aac31c6][field_69b08f25cb5e5][]\" value=\"sacrum\"\/> Sacrum<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f25cb5e5-bas_dos\" name=\"acf[field_698da0aac31c6][field_69b08f25cb5e5][]\" value=\"bas_dos\"\/> Bas du dos<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69b08f2bcb5e6\" data-name=\"douleurs_associees\" data-type=\"checkbox\" data-key=\"field_69b08f2bcb5e6\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da0aac31c6-field_69b08f2bcb5e6-label\">Douleurs associ\u00e9es<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da0aac31c6][field_69b08f2bcb5e6]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698da0aac31c6-field_69b08f2bcb5e6-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f2bcb5e6-aines\" name=\"acf[field_698da0aac31c6][field_69b08f2bcb5e6][]\" value=\"aines\"\/> Aines<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f2bcb5e6-fesses\" name=\"acf[field_698da0aac31c6][field_69b08f2bcb5e6][]\" value=\"fesses\"\/> Fesses<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b08f2bcb5e6-cuisses\" name=\"acf[field_698da0aac31c6][field_69b08f2bcb5e6][]\" value=\"cuisses\"\/> Cuisses (face post\u00e9rieure)<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69b09074cb5e7\" data-name=\"autre_zone\" data-type=\"checkbox\" data-key=\"field_69b09074cb5e7\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da0aac31c6-field_69b09074cb5e7-label\">Autre zone de douleur ?<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da0aac31c6][field_69b09074cb5e7]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_698da0aac31c6-field_69b09074cb5e7-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_698da0aac31c6-field_69b09074cb5e7-oui\" name=\"acf[field_698da0aac31c6][field_69b09074cb5e7][]\" value=\"oui\"\/> oui<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69b0913fcb5e8\" data-name=\"preciser_autre_zone\" data-type=\"text\" data-key=\"field_69b0913fcb5e8\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69b09074cb5e7&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;oui&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698da0aac31c6-field_69b0913fcb5e8\">Pr\u00e9ciser la zone<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_698da0aac31c6-field_69b0913fcb5e8\" name=\"acf[field_698da0aac31c6][field_69b0913fcb5e8]\"\/><\/div><\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-698da20cc31c8 is-required\" data-name=\"lateralisation\" data-type=\"radio\" data-key=\"field_698da20cc31c8\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_698da20cc31c8-label\">Lat\u00e9ralisation des douleurs <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_698da20cc31c8]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_698da20cc31c8-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_698da20cc31c8-droite\" name=\"acf[field_698da20cc31c8]\" value=\"droite\" checked=\"checked\"\/>Droite<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698da20cc31c8-gauche\" name=\"acf[field_698da20cc31c8]\" value=\"gauche\"\/>Gauche<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698da20cc31c8-bilaterale\" name=\"acf[field_698da20cc31c8]\" value=\"bilaterale\"\/>Bilat\u00e9rale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698da20cc31c8-centrale\" name=\"acf[field_698da20cc31c8]\" value=\"centrale\"\/>Centrale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_698da20cc31c8-non_precise\" name=\"acf[field_698da20cc31c8]\" value=\"non_precise\"\/>Non pr\u00e9cis\u00e9e<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698d8d91ffff0 is-required\" data-name=\"intensite_douleur-avant\" data-type=\"select\" data-key=\"field_698d8d91ffff0\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698d8d91ffff0\">Intensit\u00e9 moyenne de la douleur AVANT TRAITEMENT <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_698d8d91ffff0\" class=\"\" name=\"acf[field_698d8d91ffff0]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-698da154c31c7\" data-name=\"preciser_localisations\" data-type=\"textarea\" data-key=\"field_698da154c31c7\">\n<div class=\"acf-label\">\n<label for=\"acf-field_698da154c31c7\">Apporter des pr\u00e9cisions sur la manifestation des douleurs<\/label><p class=\"description\">Vous pouvez pr\u00e9ciser ici tout \u00e9l\u00e9ment utile : type de sensation (br\u00fblure, d\u00e9charge, tiraillement\u2026), circonstances d\u2019apparition ou d\u2019aggravation (position assise, marche, effort\u2026), localisation plus pr\u00e9cise, irradiation \u00e9ventuelle, \u00e9volution dans le temps ou tout autre d\u00e9tail que vous jugez important.<\/p><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_698da154c31c7\" name=\"acf[field_698da154c31c7]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-repeater acf-field-69ae81919b864\" data-name=\"3_episode_therapeutique\" data-type=\"repeater\" data-key=\"field_69ae81919b864\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864\">3. EPISODE THERAPEUTIQUE<\/label><p class=\"description\">D\u00e9crivez chaque \u00e9pisode th\u00e9rapeutique significatif de votre parcours.\r\n\r\nUn \u00e9pisode correspond \u00e0 une prise en charge pr\u00e9cise, par exemple :\r\n- un traitement\r\n- une intervention\r\n- un suivi avec un praticien ou une \u00e9quipe de soins\r\n\r\nSi vous avez eu plusieurs traitements ou plusieurs praticiens, cliquez sur\r\n\u00ab Ajouter un \u00e9pisode th\u00e9rapeutique \u00bb pour les d\u00e9crire s\u00e9par\u00e9ment.\r\nChaque \u00e9pisode doit correspondre \u00e0 une \u00e9tape identifiable de votre parcours.<\/p><\/div>\n<div class=\"acf-input\">\n\t\t<div class=\"acf-repeater -block\" data-min=\"1\" data-max=\"0\" data-pagination=\"0\" data-prefix=\"acf\">\n\t\t\t<input type=\"hidden\" name=\"acf[field_69ae81919b864]\" value=\"\" class=\"acf-repeater-hidden-input\"\/>\t\t\t<table class=\"acf-table\">\n\t\t\t\t\t\t\t\t<tbody>\n\t\t\t\t\t<tr class=\"acf-row\" data-id=\"row-0\">\t\t<td class=\"acf-row-handle order\" title=\"Drag to reorder\">\n\t\t\t\t\t\t\t<a class=\"acf-icon -collapse small\" href=\"#\" data-event=\"collapse-row\" title=\"Click to toggle\"><\/a>\n\t\t\t\t\t\t<span class=\"acf-row-number\" title=\"Click to reorder\">1<\/span>\t\t<\/td>\n\t\t<td class=\"acf-fields\"><div class=\"acf-field acf-field-message acf-field-698efef731c16\" data-name=\"31_traitement\" data-type=\"message\" data-key=\"field_698efef731c16\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698efef731c16\">3.1. TRAITEMENT<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-698d8f73b76a8 is-required -collapsed-target\" data-name=\"traitement_adopte\" data-type=\"checkbox\" data-key=\"field_698d8f73b76a8\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-label\">Type(s) de prise en charge <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-M\u00e9dicamenteuse\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"M\u00e9dicamenteuse\"\/> M\u00e9dicamenteuse<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-R\u00e9\u00e9ducation-\/-kin\u00e9sith\u00e9rapie\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"R\u00e9\u00e9ducation \/ kin\u00e9sith\u00e9rapie\"\/> R\u00e9\u00e9ducation \/ kin\u00e9sith\u00e9rapie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Th\u00e9rapie-manuelle\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Th\u00e9rapie manuelle\"\/> Th\u00e9rapie manuelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Infiltration-\/-injection\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Infiltration \/ injection\"\/> Infiltration \/ injection<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Neuromodulation\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Neuromodulation\"\/> Neuromodulation<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Chirurgie\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Chirurgie\"\/> Chirurgie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Dispositif-m\u00e9dical-(assise,-orth\u00e8se,-coussin)\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Dispositif m\u00e9dical (assise, orth\u00e8se, coussin)\"\/> Dispositif m\u00e9dical (assise, orth\u00e8se, coussin)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Approche-psycho-corporelle\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Approche psycho-corporelle\"\/> Approche psycho-corporelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Pratiques-alternatives\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Pratiques alternatives\"\/> Pratiques alternatives<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d8f73b76a8-Autre\" name=\"acf[field_69ae81919b864][row-0][field_698d8f73b76a8][]\" value=\"Autre\"\/> Autre<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad385d59c2c\" data-name=\"traitement_adopte_autre\" data-type=\"text\" data-key=\"field_69ad385d59c2c\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad385d59c2c\">Si autre, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ad385d59c2c\" name=\"acf[field_69ae81919b864][row-0][field_69ad385d59c2c]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-69ad4aa98b2ce\" data-name=\"traitement_adopte_chirurgie\" data-type=\"radio\" data-key=\"field_69ad4aa98b2ce\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;}]]\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-label\">Si traitement chirurgical,  indiquer le type d&#039;intervention<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-decompression-nerveuse\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"D\u00e9compression nerveuse\" checked=\"checked\"\/>D\u00e9compression nerveuse<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-chirurgie-discale-discectomie\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"Chirurgie discale (discectomie)\"\/>Chirurgie discale (discectomie)<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-fusion-vertebrale\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"Fusion vert\u00e9brale\"\/>Fusion vert\u00e9brale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-coccygectomie\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"Coccygectomie\"\/>Coccygectomie<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-liberation-ligamentaire\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"Lib\u00e9ration ligamentaire\"\/>Lib\u00e9ration ligamentaire<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad4aa98b2ce-autre\" name=\"acf[field_69ae81919b864][row-0][field_69ad4aa98b2ce]\" value=\"Autre\"\/>Autre<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad4b289c770\" data-name=\"traitement_adopte_chirurgie_autre\" data-type=\"text\" data-key=\"field_69ad4b289c770\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;},{&quot;field&quot;:&quot;field_69ad4aa98b2ce&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad4b289c770\">Si autre traitement chirurgical, pr\u00e9ciser<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ad4b289c770\" name=\"acf[field_69ae81919b864][row-0][field_69ad4b289c770]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad4d9c9c0b4\" data-name=\"traitement_adopte_chirurgie_precision\" data-type=\"text\" data-key=\"field_69ad4d9c9c0b4\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad4d9c9c0b4\">Pr\u00e9cisions sur le traitement chirurgical<\/label><p class=\"description\">Pr\u00e9cisez si possible : type exact d\u2019intervention, niveau op\u00e9r\u00e9, date ou ann\u00e9e de l\u2019intervention, r\u00e9sultats observ\u00e9s.\r\nexemple de r\u00e9ponse : Discectomie L5-S1 en 2022 pour hernie discale compressive.\r\nAm\u00e9lioration de la sciatique mais persistance des douleurs en position assise.<\/p><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ad4d9c9c0b4\" name=\"acf[field_69ae81919b864][row-0][field_69ad4d9c9c0b4]\" placeholder=\"Pr\u00e9cisions sur le traitement chirugical\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69ad40c35a216 is-required\" data-name=\"traitement_adopte_cible\" data-type=\"checkbox\" data-key=\"field_69ad40c35a216\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-label\">Structure(s) cibl\u00e9e(s) <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Muscles-du-plancher-pelvien\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Muscles du plancher pelvien\"\/> Muscles du plancher pelvien<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Muscles-lombaires-ou-fessiers\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Muscles lombaires ou fessiers\"\/> Muscles lombaires ou fessiers<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Nerf-pudendal\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Nerf pudendal\"\/> Nerf pudendal<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Nerfs-clun\u00e9aux\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Nerfs clun\u00e9aux\"\/> Nerfs clun\u00e9aux<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Racines-nerveuses-lombaires-ou-sacr\u00e9es\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Racines nerveuses lombaires ou sacr\u00e9es\"\/> Racines nerveuses lombaires ou sacr\u00e9es<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Articulation-sacro-iliaque\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Articulation sacro-iliaque\"\/> Articulation sacro-iliaque<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Articulations-lombaires-(facettes)\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Articulations lombaires (facettes)\"\/> Articulations lombaires (facettes)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Disque-intervert\u00e9bral\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Disque intervert\u00e9bral\"\/> Disque intervert\u00e9bral<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Coccyx\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Coccyx\"\/> Coccyx<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Ganglion-de-l\u2019impar\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Ganglion de l\u2019impar\"\/> Ganglion de l\u2019impar<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Ligaments-sacro-tub\u00e9raux-\/-sacro-\u00e9pineux\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Ligaments sacro-tub\u00e9raux \/ sacro-\u00e9pineux\"\/> Ligaments sacro-tub\u00e9raux \/ sacro-\u00e9pineux<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Fascias-pelviens\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Fascias pelviens\"\/> Fascias pelviens<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_69ad40c35a216-Autre\" name=\"acf[field_69ae81919b864][row-0][field_69ad40c35a216][]\" value=\"Autre\"\/> Autre<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad41d15a217\" data-name=\"traitement_adopte_cible_autre\" data-type=\"text\" data-key=\"field_69ad41d15a217\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ad40c35a216&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad41d15a217\">Si autre, pr\u00e9ciser : (copier)<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ad41d15a217\" name=\"acf[field_69ae81919b864][row-0][field_69ad41d15a217]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-69ad423a53901 is-required\" data-name=\"traitement_adopte_objectif\" data-type=\"radio\" data-key=\"field_69ad423a53901\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-label\">Objectif th\u00e9rapeutique principal <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-diminuer-la-douleur\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Diminuer la douleur\" checked=\"checked\"\/>Diminuer la douleur<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-relacher-une-tension-musculaire\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Rel\u00e2cher une tension musculaire\"\/>Rel\u00e2cher une tension musculaire<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-decomprimer-un-nerf\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"D\u00e9comprimer un nerf\"\/>D\u00e9comprimer un nerf<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-reduire-linflammation\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"R\u00e9duire l\u2019inflammation\"\/>R\u00e9duire l\u2019inflammation<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-ameliorer-la-mobilite\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Am\u00e9liorer la mobilit\u00e9\"\/>Am\u00e9liorer la mobilit\u00e9<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-stabiliser-une-articulation\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Stabiliser une articulation\"\/>Stabiliser une articulation<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-ameliorer-la-tolerance-a-la-position-assise\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Am\u00e9liorer la tol\u00e9rance \u00e0 la position assise\"\/>Am\u00e9liorer la tol\u00e9rance \u00e0 la position assise<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-restaurer-la-fonction-marche-position-assise-activite\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Restaurer la fonction (marche, position assise, activit\u00e9)\"\/>Restaurer la fonction (marche, position assise, activit\u00e9)<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-row-0-field_69ad423a53901-autre\" name=\"acf[field_69ae81919b864][row-0][field_69ad423a53901]\" value=\"Autre\"\/>Autre<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad3f5c59c2e\" data-name=\"traitement_adopte_objectif_autre\" data-type=\"text\" data-key=\"field_69ad3f5c59c2e\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ad423a53901&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad3f5c59c2e\">Si autre, pr\u00e9ciser<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ad3f5c59c2e\" name=\"acf[field_69ae81919b864][row-0][field_69ad3f5c59c2e]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-69ad48b11ebfe\" data-name=\"traitement_adopte__objectif_precision\" data-type=\"textarea\" data-key=\"field_69ad48b11ebfe\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ad48b11ebfe\">Pr\u00e9cisions utiles sur le traitement<\/label><p class=\"description\">Pr\u00e9cisez si utile : nom exact du traitement, nombre de s\u00e9ances ou d\u2019injections, fr\u00e9quence, zone trait\u00e9e,  \u00e9l\u00e9ment ayant sembl\u00e9 le plus utile, temps d'action du traitement<\/p><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-row-0-field_69ad48b11ebfe\" name=\"acf[field_69ae81919b864][row-0][field_69ad48b11ebfe]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-698eff0d31c17\" data-type=\"message\" data-key=\"field_698eff0d31c17\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698eff0d31c17\">3.1. PRATICIEN<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69ae9798e7837\" style=\"width:33%;\" data-name=\"titre_du_praticien\" data-type=\"select\" data-key=\"field_69ae9798e7837\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ae9798e7837\">Titre du praticien<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_69ae9798e7837\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_69ae9798e7837]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"Docteur\">Docteur<\/option><option value=\"Professeur\">Professeur<\/option><option value=\"Dipl\u00f4m\u00e9 d&#039;\u00c9tat\">Dipl\u00f4m\u00e9 d&#039;\u00c9tat<\/option><option value=\"Th\u00e9rapeute\">Th\u00e9rapeute<\/option><option value=\"Autre\">Autre<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d9521152b8 is-required\" style=\"width:33%;\" data-name=\"nom_praticien\" data-type=\"text\" data-key=\"field_698d9521152b8\" data-required=\"1\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698d9521152b8\">Nom du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_698d9521152b8\" name=\"acf[field_69ae81919b864][row-0][field_698d9521152b8]\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae97ebe7838\" style=\"width:33%;\" data-name=\"prenom_praticien\" data-type=\"text\" data-key=\"field_69ae97ebe7838\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ae97ebe7838\">Pr\u00e9nom du Praticien<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ae97ebe7838\" name=\"acf[field_69ae81919b864][row-0][field_69ae97ebe7838]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d9694152b9 is-required\" style=\"width:50%;\" data-name=\"ville_praticien\" data-type=\"text\" data-key=\"field_698d9694152b9\" data-required=\"1\" data-width=\"50\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698d9694152b9\">Ville du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_698d9694152b9\" name=\"acf[field_69ae81919b864][row-0][field_698d9694152b9]\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69ae993be783a\" style=\"width:30%;\" data-name=\"pays_praticien\" data-type=\"select\" data-key=\"field_69ae993be783a\" data-width=\"30\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ae993be783a\">Pays du Praticien<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_69ae993be783a\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_69ae993be783a]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"France\">France<\/option><option value=\"Belgique\">Belgique<\/option><option value=\"Suisse\">Suisse<\/option><option value=\"Canada\">Canada<\/option><option value=\"Autre\">Autre<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae99e7e783b\" style=\"width:30%;\" data-name=\"si_autre_pays_preciser_:\" data-type=\"text\" data-key=\"field_69ae99e7e783b\" data-width=\"30\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ae993be783a&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ae99e7e783b\">Si autre pays, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ae99e7e783b\" name=\"acf[field_69ae81919b864][row-0][field_69ae99e7e783b]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae9915e7839 is-required\" style=\"width:20%;\" data-name=\"code_postal\" data-type=\"text\" data-key=\"field_69ae9915e7839\" data-required=\"1\" data-width=\"20\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69ae9915e7839\">Code postal <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69ae9915e7839\" name=\"acf[field_69ae81919b864][row-0][field_69ae9915e7839]\" maxlength=\"4\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698da615c31ca is-required\" data-name=\"specialite_du_praticien\" data-type=\"select\" data-key=\"field_698da615c31ca\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698da615c31ca\">Sp\u00e9cialit\u00e9 du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_698da615c31ca\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_698da615c31ca]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"kinesitherapeute\">Kin\u00e9sith\u00e9rapeute<\/option><option value=\"osteopathe\">Ost\u00e9opathe<\/option><option value=\"infirmier\">Infirmier \/ Infirmi\u00e8re<\/option><option value=\"sage_femme\">Sage-femme<\/option><option value=\"\" selected=\"selected\" data-i=\"0\"><\/option><option value=\"medecin_generaliste\">M\u00e9decin g\u00e9n\u00e9raliste<\/option><option value=\"algologue\">Algologue<\/option><option value=\"chirurgien\">Chirurgien<\/option><option value=\"gastro_enterologue\">Gastro-ent\u00e9rologue<\/option><option value=\"gynecologue\">Gyn\u00e9cologue<\/option><option value=\"neurologue\">Neurologue<\/option><option value=\"proctologue\">Proctologue<\/option><option value=\"psychiatre\">Psychiatre<\/option><option value=\"psychologue\">Psychologue<\/option><option value=\"radiologue\">Radiologue<\/option><option value=\"rhumatologue\">Rhumatologue<\/option><option value=\"sexologue\">Sexologue<\/option><option value=\"urologue\">Urologue<\/option><option value=\"autre\">Autre sp\u00e9cialit\u00e9<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69cced69023d6\" data-name=\"autre_specialite\" data-type=\"text\" data-key=\"field_69cced69023d6\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698da615c31ca&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69cced69023d6\">Si autre sp\u00e9cialit\u00e9, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_69cced69023d6\" name=\"acf[field_69ae81919b864][row-0][field_69cced69023d6]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-698eff2931c18\" data-name=\"33_impact_qualite_de_vie\" data-type=\"message\" data-key=\"field_698eff2931c18\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698eff2931c18\">3.3. IMPACT QUALIT\u00c9 DE VIE<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-698d96c1152ba is-required\" data-name=\"effet_positif_ressenti\" data-type=\"checkbox\" data-key=\"field_698d96c1152ba\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-label\">Effet positif ressenti (dans vos mots) <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">D\u00e9crivez l\u2019am\u00e9lioration que vous avez constat\u00e9e apr\u00e8s ce traitement.<\/p><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-douleur\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"douleur\"\/> Diminution de la douleur<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-assise\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"assise\"\/> Meilleure tol\u00e9rance \u00e0 l\u2019assise<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-assise_duree\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"assise_duree\"\/> Augmentation notable de la dur\u00e9e d\u2019assise sans douleur<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-mobilite\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"mobilite\"\/> Am\u00e9lioration de la mobilit\u00e9<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-miction\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"miction\"\/> Am\u00e9lioration urinaire<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-sexualite\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"sexualite\"\/> Am\u00e9lioration sexuelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-sommeil\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"sommeil\"\/> Am\u00e9lioration du sommeil<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-travail\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"travail\"\/> Reprise du travail \/ activit\u00e9 professionnelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-vie_sociale\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"vie_sociale\"\/> Reprise d'une vie sociale<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-conduite_transport\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"conduite_transport\"\/> Reprise de la conduite et des transports<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-qualite_vie\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"qualite_vie\"\/> Am\u00e9lioration globale de la qualit\u00e9 de vie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-row-0-field_698d96c1152ba-autre\" name=\"acf[field_69ae81919b864][row-0][field_698d96c1152ba][]\" value=\"autre\"\/> Autre am\u00e9lioration<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-698d972d152bb\" data-name=\"effets_qualite_vie\" data-type=\"textarea\" data-key=\"field_698d972d152bb\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698d972d152bb\">Pr\u00e9cisez les effets induits sur votre qualit\u00e9 de vie<\/label><p class=\"description\">Si ce traitement a eu des effets positifs sur votre quotidien, d\u00e9crivez-les.\r\n\r\nPar exemple :\r\n\u2013 reprise d\u2019activit\u00e9s sociales\r\n\u2013 am\u00e9lioration de l\u2019autonomie dans la vie quotidienne\r\n\u2013 possibilit\u00e9 de rester assis plus longtemps\r\n\u2013 reprise d\u2019une activit\u00e9 professionnelle\r\n\u2013 am\u00e9lioration du sommeil\r\n\u2013 diminution des limitations dans les d\u00e9placements\r\n\r\nIndiquez les changements concrets que vous avez observ\u00e9s dans votre vie quotidienne.<\/p><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-row-0-field_698d972d152bb\" name=\"acf[field_69ae81919b864][row-0][field_698d972d152bb]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698f531e79bbc\" data-name=\"duree_assise_max_post_traitement\" data-type=\"select\" data-key=\"field_698f531e79bbc\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698f531e79bbc\">Dur\u00e9e maximale d\u2019assise tol\u00e9r\u00e9e sans douleur significative apr\u00e8s traitement<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_698f531e79bbc\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_698f531e79bbc]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"moins_15\">Moins de 15 minutes<\/option><option value=\"15_30\">15 \u00e0 30 minutes<\/option><option value=\"30_60\">30 \u00e0 60 minutes<\/option><option value=\"1_2h\">1 \u00e0 2 heures<\/option><option value=\"2_3h\">2 \u00e0 3 heures (reprise activit\u00e9 possible)<\/option><option value=\"plus_3h\">Plus de 3 heures (quasi normalisation fonctionnelle)<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698d9388152b6 is-required\" data-name=\"delai_apparition_effets\" data-type=\"select\" data-key=\"field_698d9388152b6\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698d9388152b6\">D\u00e9lai apparition des effets <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">Indiquez le d\u00e9lai approximatif apr\u00e8s lequel les effets positifs de ce traitement sont apparus.\r\n\r\nSi les choix propos\u00e9s ne correspondent pas exactement \u00e0 votre situation, vous pouvez apporter des pr\u00e9cisions dans le champ \u00ab Commentaire \u00bb situ\u00e9 plus bas dans le questionnaire.<\/p><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_698d9388152b6\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_698d9388152b6]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"immediat\">Imm\u00e9diat (pendant ou juste apr\u00e8s la s\u00e9ance)<\/option><option value=\"moins_24h\">Moins de 24 heures<\/option><option value=\"quelques_jours\">Quelques jours<\/option><option value=\"1_2_semaines\">1 \u00e0 2 semaines<\/option><option value=\"plus_1_mois\">Plus d\u2019un mois<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d93d9152b7\" data-name=\"commentaire_effet\" data-type=\"text\" data-key=\"field_698d93d9152b7\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698d93d9152b7\">Commentaire sur l\u2019effet<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-row-0-field_698d93d9152b7\" name=\"acf[field_69ae81919b864][row-0][field_698d93d9152b7]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698da54fc31c9 is-required\" data-name=\"duree_effets\" data-type=\"select\" data-key=\"field_698da54fc31c9\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698da54fc31c9\">Dur\u00e9e des effets <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">Indiquez combien de temps les effets positifs de ce traitement ont dur\u00e9.\r\nSi les choix propos\u00e9s ne correspondent pas exactement \u00e0 votre situation,\r\nvous pouvez apporter des pr\u00e9cisions dans le champ \u00ab Commentaire \u00bb\r\nsitu\u00e9 plus bas dans le questionnaire.<\/p><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_698da54fc31c9\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_698da54fc31c9]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"quelques_heures\">Quelques heures<\/option><option value=\"1_3_jours\">1 \u00e0 3 jours<\/option><option value=\"1_semaine\">Environ 1 semaine<\/option><option value=\"plus_1_mois\">Plus d\u2019un mois<\/option><option value=\"effet_durable\">Effet durable \/ stabilis\u00e9<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-698da9b37dfcb\" data-name=\"commentaire_effets\" data-type=\"textarea\" data-key=\"field_698da9b37dfcb\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_698da9b37dfcb\">Commentaire global (am\u00e9lioration, d\u00e9lai d\u2019apparition, dur\u00e9e, nuances)<\/label><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-row-0-field_698da9b37dfcb\" name=\"acf[field_69ae81919b864][row-0][field_698da9b37dfcb]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69b092b7f83d7\" data-name=\"intensite_douleur-apres\" data-type=\"select\" data-key=\"field_69b092b7f83d7\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-row-0-field_69b092b7f83d7\">Intensit\u00e9 moyenne de la douleur APRES TRAITEMENT<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-row-0-field_69b092b7f83d7\" class=\"\" name=\"acf[field_69ae81919b864][row-0][field_69b092b7f83d7]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/div>\n<\/div>\n<\/td>\t\t<td class=\"acf-row-handle remove\">\n\t\t\t<a class=\"acf-icon -plus small acf-js-tooltip hide-on-shift\" href=\"#\" data-event=\"add-row\" title=\"Add row\"><\/a>\n\t\t\t<a class=\"acf-icon -duplicate small acf-js-tooltip show-on-shift\" href=\"#\" data-event=\"duplicate-row\" title=\"Duplicate row\"><\/a>\n\t\t\t<a class=\"acf-icon -minus small acf-js-tooltip\" href=\"#\" data-event=\"remove-row\" title=\"Remove row\"><\/a>\n\t\t<\/td>\n\t\t<\/tr><tr class=\"acf-row acf-clone\" data-id=\"acfcloneindex\">\t\t<td class=\"acf-row-handle order\" title=\"Drag to reorder\">\n\t\t\t\t\t\t\t<a class=\"acf-icon -collapse small\" href=\"#\" data-event=\"collapse-row\" title=\"Click to toggle\"><\/a>\n\t\t\t\t\t\t<span class=\"acf-row-number\" title=\"Click to reorder\">1<\/span>\t\t<\/td>\n\t\t<td class=\"acf-fields\"><div class=\"acf-field acf-field-message acf-field-698efef731c16\" data-name=\"31_traitement\" data-type=\"message\" data-key=\"field_698efef731c16\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698efef731c16\">3.1. TRAITEMENT<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-698d8f73b76a8 is-required -collapsed-target\" data-name=\"traitement_adopte\" data-type=\"checkbox\" data-key=\"field_698d8f73b76a8\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-label\">Type(s) de prise en charge <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-M\u00e9dicamenteuse\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"M\u00e9dicamenteuse\"\/> M\u00e9dicamenteuse<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-R\u00e9\u00e9ducation-\/-kin\u00e9sith\u00e9rapie\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"R\u00e9\u00e9ducation \/ kin\u00e9sith\u00e9rapie\"\/> R\u00e9\u00e9ducation \/ kin\u00e9sith\u00e9rapie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Th\u00e9rapie-manuelle\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Th\u00e9rapie manuelle\"\/> Th\u00e9rapie manuelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Infiltration-\/-injection\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Infiltration \/ injection\"\/> Infiltration \/ injection<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Neuromodulation\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Neuromodulation\"\/> Neuromodulation<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Chirurgie\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Chirurgie\"\/> Chirurgie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Dispositif-m\u00e9dical-(assise,-orth\u00e8se,-coussin)\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Dispositif m\u00e9dical (assise, orth\u00e8se, coussin)\"\/> Dispositif m\u00e9dical (assise, orth\u00e8se, coussin)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Approche-psycho-corporelle\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Approche psycho-corporelle\"\/> Approche psycho-corporelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Pratiques-alternatives\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Pratiques alternatives\"\/> Pratiques alternatives<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d8f73b76a8-Autre\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d8f73b76a8][]\" value=\"Autre\"\/> Autre<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad385d59c2c\" data-name=\"traitement_adopte_autre\" data-type=\"text\" data-key=\"field_69ad385d59c2c\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad385d59c2c\">Si autre, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad385d59c2c\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad385d59c2c]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-69ad4aa98b2ce\" data-name=\"traitement_adopte_chirurgie\" data-type=\"radio\" data-key=\"field_69ad4aa98b2ce\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;}]]\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-label\">Si traitement chirurgical,  indiquer le type d&#039;intervention<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-decompression-nerveuse\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"D\u00e9compression nerveuse\" checked=\"checked\"\/>D\u00e9compression nerveuse<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-chirurgie-discale-discectomie\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"Chirurgie discale (discectomie)\"\/>Chirurgie discale (discectomie)<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-fusion-vertebrale\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"Fusion vert\u00e9brale\"\/>Fusion vert\u00e9brale<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-coccygectomie\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"Coccygectomie\"\/>Coccygectomie<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-liberation-ligamentaire\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"Lib\u00e9ration ligamentaire\"\/>Lib\u00e9ration ligamentaire<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4aa98b2ce-autre\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4aa98b2ce]\" value=\"Autre\"\/>Autre<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad4b289c770\" data-name=\"traitement_adopte_chirurgie_autre\" data-type=\"text\" data-key=\"field_69ad4b289c770\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;},{&quot;field&quot;:&quot;field_69ad4aa98b2ce&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4b289c770\">Si autre traitement chirurgical, pr\u00e9ciser<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4b289c770\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4b289c770]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad4d9c9c0b4\" data-name=\"traitement_adopte_chirurgie_precision\" data-type=\"text\" data-key=\"field_69ad4d9c9c0b4\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698d8f73b76a8&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Chirurgie&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4d9c9c0b4\">Pr\u00e9cisions sur le traitement chirurgical<\/label><p class=\"description\">Pr\u00e9cisez si possible : type exact d\u2019intervention, niveau op\u00e9r\u00e9, date ou ann\u00e9e de l\u2019intervention, r\u00e9sultats observ\u00e9s.\r\nexemple de r\u00e9ponse : Discectomie L5-S1 en 2022 pour hernie discale compressive.\r\nAm\u00e9lioration de la sciatique mais persistance des douleurs en position assise.<\/p><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad4d9c9c0b4\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad4d9c9c0b4]\" placeholder=\"Pr\u00e9cisions sur le traitement chirugical\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69ad40c35a216 is-required\" data-name=\"traitement_adopte_cible\" data-type=\"checkbox\" data-key=\"field_69ad40c35a216\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-label\">Structure(s) cibl\u00e9e(s) <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Muscles-du-plancher-pelvien\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Muscles du plancher pelvien\"\/> Muscles du plancher pelvien<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Muscles-lombaires-ou-fessiers\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Muscles lombaires ou fessiers\"\/> Muscles lombaires ou fessiers<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Nerf-pudendal\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Nerf pudendal\"\/> Nerf pudendal<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Nerfs-clun\u00e9aux\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Nerfs clun\u00e9aux\"\/> Nerfs clun\u00e9aux<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Racines-nerveuses-lombaires-ou-sacr\u00e9es\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Racines nerveuses lombaires ou sacr\u00e9es\"\/> Racines nerveuses lombaires ou sacr\u00e9es<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Articulation-sacro-iliaque\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Articulation sacro-iliaque\"\/> Articulation sacro-iliaque<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Articulations-lombaires-(facettes)\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Articulations lombaires (facettes)\"\/> Articulations lombaires (facettes)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Disque-intervert\u00e9bral\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Disque intervert\u00e9bral\"\/> Disque intervert\u00e9bral<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Coccyx\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Coccyx\"\/> Coccyx<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Ganglion-de-l\u2019impar\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Ganglion de l\u2019impar\"\/> Ganglion de l\u2019impar<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Ligaments-sacro-tub\u00e9raux-\/-sacro-\u00e9pineux\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Ligaments sacro-tub\u00e9raux \/ sacro-\u00e9pineux\"\/> Ligaments sacro-tub\u00e9raux \/ sacro-\u00e9pineux<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Fascias-pelviens\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Fascias pelviens\"\/> Fascias pelviens<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad40c35a216-Autre\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad40c35a216][]\" value=\"Autre\"\/> Autre<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad41d15a217\" data-name=\"traitement_adopte_cible_autre\" data-type=\"text\" data-key=\"field_69ad41d15a217\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ad40c35a216&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad41d15a217\">Si autre, pr\u00e9ciser : (copier)<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad41d15a217\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad41d15a217]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-69ad423a53901 is-required\" data-name=\"traitement_adopte_objectif\" data-type=\"radio\" data-key=\"field_69ad423a53901\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-label\">Objectif th\u00e9rapeutique principal <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-diminuer-la-douleur\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Diminuer la douleur\" checked=\"checked\"\/>Diminuer la douleur<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-relacher-une-tension-musculaire\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Rel\u00e2cher une tension musculaire\"\/>Rel\u00e2cher une tension musculaire<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-decomprimer-un-nerf\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"D\u00e9comprimer un nerf\"\/>D\u00e9comprimer un nerf<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-reduire-linflammation\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"R\u00e9duire l\u2019inflammation\"\/>R\u00e9duire l\u2019inflammation<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-ameliorer-la-mobilite\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Am\u00e9liorer la mobilit\u00e9\"\/>Am\u00e9liorer la mobilit\u00e9<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-stabiliser-une-articulation\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Stabiliser une articulation\"\/>Stabiliser une articulation<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-ameliorer-la-tolerance-a-la-position-assise\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Am\u00e9liorer la tol\u00e9rance \u00e0 la position assise\"\/>Am\u00e9liorer la tol\u00e9rance \u00e0 la position assise<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-restaurer-la-fonction-marche-position-assise-activite\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Restaurer la fonction (marche, position assise, activit\u00e9)\"\/>Restaurer la fonction (marche, position assise, activit\u00e9)<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad423a53901-autre\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad423a53901]\" value=\"Autre\"\/>Autre<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad3f5c59c2e\" data-name=\"traitement_adopte_objectif_autre\" data-type=\"text\" data-key=\"field_69ad3f5c59c2e\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ad423a53901&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad3f5c59c2e\">Si autre, pr\u00e9ciser<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad3f5c59c2e\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad3f5c59c2e]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-69ad48b11ebfe\" data-name=\"traitement_adopte__objectif_precision\" data-type=\"textarea\" data-key=\"field_69ad48b11ebfe\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ad48b11ebfe\">Pr\u00e9cisions utiles sur le traitement<\/label><p class=\"description\">Pr\u00e9cisez si utile : nom exact du traitement, nombre de s\u00e9ances ou d\u2019injections, fr\u00e9quence, zone trait\u00e9e,  \u00e9l\u00e9ment ayant sembl\u00e9 le plus utile, temps d'action du traitement<\/p><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-acfcloneindex-field_69ad48b11ebfe\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ad48b11ebfe]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-698eff0d31c17\" data-type=\"message\" data-key=\"field_698eff0d31c17\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698eff0d31c17\">3.1. PRATICIEN<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69ae9798e7837\" style=\"width:33%;\" data-name=\"titre_du_praticien\" data-type=\"select\" data-key=\"field_69ae9798e7837\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ae9798e7837\">Titre du praticien<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_69ae9798e7837\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ae9798e7837]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"Docteur\">Docteur<\/option><option value=\"Professeur\">Professeur<\/option><option value=\"Dipl\u00f4m\u00e9 d&#039;\u00c9tat\">Dipl\u00f4m\u00e9 d&#039;\u00c9tat<\/option><option value=\"Th\u00e9rapeute\">Th\u00e9rapeute<\/option><option value=\"Autre\">Autre<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d9521152b8 is-required\" style=\"width:33%;\" data-name=\"nom_praticien\" data-type=\"text\" data-key=\"field_698d9521152b8\" data-required=\"1\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698d9521152b8\">Nom du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d9521152b8\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d9521152b8]\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae97ebe7838\" style=\"width:33%;\" data-name=\"prenom_praticien\" data-type=\"text\" data-key=\"field_69ae97ebe7838\" data-width=\"33\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ae97ebe7838\">Pr\u00e9nom du Praticien<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ae97ebe7838\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ae97ebe7838]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d9694152b9 is-required\" style=\"width:50%;\" data-name=\"ville_praticien\" data-type=\"text\" data-key=\"field_698d9694152b9\" data-required=\"1\" data-width=\"50\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698d9694152b9\">Ville du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d9694152b9\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d9694152b9]\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69ae993be783a\" style=\"width:30%;\" data-name=\"pays_praticien\" data-type=\"select\" data-key=\"field_69ae993be783a\" data-width=\"30\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ae993be783a\">Pays du Praticien<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_69ae993be783a\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ae993be783a]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"France\">France<\/option><option value=\"Belgique\">Belgique<\/option><option value=\"Suisse\">Suisse<\/option><option value=\"Canada\">Canada<\/option><option value=\"Autre\">Autre<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae99e7e783b\" style=\"width:30%;\" data-name=\"si_autre_pays_preciser_:\" data-type=\"text\" data-key=\"field_69ae99e7e783b\" data-width=\"30\" data-conditions=\"[[{&quot;field&quot;:&quot;field_69ae993be783a&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;Autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ae99e7e783b\">Si autre pays, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ae99e7e783b\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ae99e7e783b]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ae9915e7839 is-required\" style=\"width:20%;\" data-name=\"code_postal\" data-type=\"text\" data-key=\"field_69ae9915e7839\" data-required=\"1\" data-width=\"20\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69ae9915e7839\">Code postal <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69ae9915e7839\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69ae9915e7839]\" maxlength=\"4\" required=\"required\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698da615c31ca is-required\" data-name=\"specialite_du_praticien\" data-type=\"select\" data-key=\"field_698da615c31ca\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698da615c31ca\">Sp\u00e9cialit\u00e9 du praticien <span class=\"acf-required\">*<\/span><\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_698da615c31ca\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698da615c31ca]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"kinesitherapeute\">Kin\u00e9sith\u00e9rapeute<\/option><option value=\"osteopathe\">Ost\u00e9opathe<\/option><option value=\"infirmier\">Infirmier \/ Infirmi\u00e8re<\/option><option value=\"sage_femme\">Sage-femme<\/option><option value=\"\" selected=\"selected\" data-i=\"0\"><\/option><option value=\"medecin_generaliste\">M\u00e9decin g\u00e9n\u00e9raliste<\/option><option value=\"algologue\">Algologue<\/option><option value=\"chirurgien\">Chirurgien<\/option><option value=\"gastro_enterologue\">Gastro-ent\u00e9rologue<\/option><option value=\"gynecologue\">Gyn\u00e9cologue<\/option><option value=\"neurologue\">Neurologue<\/option><option value=\"proctologue\">Proctologue<\/option><option value=\"psychiatre\">Psychiatre<\/option><option value=\"psychologue\">Psychologue<\/option><option value=\"radiologue\">Radiologue<\/option><option value=\"rhumatologue\">Rhumatologue<\/option><option value=\"sexologue\">Sexologue<\/option><option value=\"urologue\">Urologue<\/option><option value=\"autre\">Autre sp\u00e9cialit\u00e9<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69cced69023d6\" data-name=\"autre_specialite\" data-type=\"text\" data-key=\"field_69cced69023d6\" data-conditions=\"[[{&quot;field&quot;:&quot;field_698da615c31ca&quot;,&quot;operator&quot;:&quot;==&quot;,&quot;value&quot;:&quot;autre&quot;}]]\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69cced69023d6\">Si autre sp\u00e9cialit\u00e9, pr\u00e9ciser :<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_69cced69023d6\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69cced69023d6]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-698eff2931c18\" data-name=\"33_impact_qualite_de_vie\" data-type=\"message\" data-key=\"field_698eff2931c18\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698eff2931c18\">3.3. IMPACT QUALIT\u00c9 DE VIE<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-698d96c1152ba is-required\" data-name=\"effet_positif_ressenti\" data-type=\"checkbox\" data-key=\"field_698d96c1152ba\" data-required=\"1\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-label\">Effet positif ressenti (dans vos mots) <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">D\u00e9crivez l\u2019am\u00e9lioration que vous avez constat\u00e9e apr\u00e8s ce traitement.<\/p><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-douleur\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"douleur\"\/> Diminution de la douleur<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-assise\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"assise\"\/> Meilleure tol\u00e9rance \u00e0 l\u2019assise<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-assise_duree\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"assise_duree\"\/> Augmentation notable de la dur\u00e9e d\u2019assise sans douleur<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-mobilite\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"mobilite\"\/> Am\u00e9lioration de la mobilit\u00e9<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-miction\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"miction\"\/> Am\u00e9lioration urinaire<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-sexualite\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"sexualite\"\/> Am\u00e9lioration sexuelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-sommeil\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"sommeil\"\/> Am\u00e9lioration du sommeil<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-travail\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"travail\"\/> Reprise du travail \/ activit\u00e9 professionnelle<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-vie_sociale\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"vie_sociale\"\/> Reprise d'une vie sociale<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-conduite_transport\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"conduite_transport\"\/> Reprise de la conduite et des transports<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-qualite_vie\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"qualite_vie\"\/> Am\u00e9lioration globale de la qualit\u00e9 de vie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d96c1152ba-autre\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d96c1152ba][]\" value=\"autre\"\/> Autre am\u00e9lioration<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-698d972d152bb\" data-name=\"effets_qualite_vie\" data-type=\"textarea\" data-key=\"field_698d972d152bb\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698d972d152bb\">Pr\u00e9cisez les effets induits sur votre qualit\u00e9 de vie<\/label><p class=\"description\">Si ce traitement a eu des effets positifs sur votre quotidien, d\u00e9crivez-les.\r\n\r\nPar exemple :\r\n\u2013 reprise d\u2019activit\u00e9s sociales\r\n\u2013 am\u00e9lioration de l\u2019autonomie dans la vie quotidienne\r\n\u2013 possibilit\u00e9 de rester assis plus longtemps\r\n\u2013 reprise d\u2019une activit\u00e9 professionnelle\r\n\u2013 am\u00e9lioration du sommeil\r\n\u2013 diminution des limitations dans les d\u00e9placements\r\n\r\nIndiquez les changements concrets que vous avez observ\u00e9s dans votre vie quotidienne.<\/p><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-acfcloneindex-field_698d972d152bb\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d972d152bb]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698f531e79bbc\" data-name=\"duree_assise_max_post_traitement\" data-type=\"select\" data-key=\"field_698f531e79bbc\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698f531e79bbc\">Dur\u00e9e maximale d\u2019assise tol\u00e9r\u00e9e sans douleur significative apr\u00e8s traitement<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_698f531e79bbc\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698f531e79bbc]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"moins_15\">Moins de 15 minutes<\/option><option value=\"15_30\">15 \u00e0 30 minutes<\/option><option value=\"30_60\">30 \u00e0 60 minutes<\/option><option value=\"1_2h\">1 \u00e0 2 heures<\/option><option value=\"2_3h\">2 \u00e0 3 heures (reprise activit\u00e9 possible)<\/option><option value=\"plus_3h\">Plus de 3 heures (quasi normalisation fonctionnelle)<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698d9388152b6 is-required\" data-name=\"delai_apparition_effets\" data-type=\"select\" data-key=\"field_698d9388152b6\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698d9388152b6\">D\u00e9lai apparition des effets <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">Indiquez le d\u00e9lai approximatif apr\u00e8s lequel les effets positifs de ce traitement sont apparus.\r\n\r\nSi les choix propos\u00e9s ne correspondent pas exactement \u00e0 votre situation, vous pouvez apporter des pr\u00e9cisions dans le champ \u00ab Commentaire \u00bb situ\u00e9 plus bas dans le questionnaire.<\/p><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_698d9388152b6\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d9388152b6]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"immediat\">Imm\u00e9diat (pendant ou juste apr\u00e8s la s\u00e9ance)<\/option><option value=\"moins_24h\">Moins de 24 heures<\/option><option value=\"quelques_jours\">Quelques jours<\/option><option value=\"1_2_semaines\">1 \u00e0 2 semaines<\/option><option value=\"plus_1_mois\">Plus d\u2019un mois<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-698d93d9152b7\" data-name=\"commentaire_effet\" data-type=\"text\" data-key=\"field_698d93d9152b7\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698d93d9152b7\">Commentaire sur l\u2019effet<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ae81919b864-acfcloneindex-field_698d93d9152b7\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698d93d9152b7]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-698da54fc31c9 is-required\" data-name=\"duree_effets\" data-type=\"select\" data-key=\"field_698da54fc31c9\" data-required=\"1\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698da54fc31c9\">Dur\u00e9e des effets <span class=\"acf-required\">*<\/span><\/label><p class=\"description\">Indiquez combien de temps les effets positifs de ce traitement ont dur\u00e9.\r\nSi les choix propos\u00e9s ne correspondent pas exactement \u00e0 votre situation,\r\nvous pouvez apporter des pr\u00e9cisions dans le champ \u00ab Commentaire \u00bb\r\nsitu\u00e9 plus bas dans le questionnaire.<\/p><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_698da54fc31c9\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698da54fc31c9]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"quelques_heures\">Quelques heures<\/option><option value=\"1_3_jours\">1 \u00e0 3 jours<\/option><option value=\"1_semaine\">Environ 1 semaine<\/option><option value=\"plus_1_mois\">Plus d\u2019un mois<\/option><option value=\"effet_durable\">Effet durable \/ stabilis\u00e9<\/option><\/select><\/div>\n<\/div>\n<div class=\"acf-field acf-field-textarea acf-field-698da9b37dfcb\" data-name=\"commentaire_effets\" data-type=\"textarea\" data-key=\"field_698da9b37dfcb\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_698da9b37dfcb\">Commentaire global (am\u00e9lioration, d\u00e9lai d\u2019apparition, dur\u00e9e, nuances)<\/label><\/div>\n<div class=\"acf-input\">\n<textarea id=\"acf-field_69ae81919b864-acfcloneindex-field_698da9b37dfcb\" name=\"acf[field_69ae81919b864][acfcloneindex][field_698da9b37dfcb]\" rows=\"8\"><\/textarea><\/div>\n<\/div>\n<div class=\"acf-field acf-field-select acf-field-69b092b7f83d7\" data-name=\"intensite_douleur-apres\" data-type=\"select\" data-key=\"field_69b092b7f83d7\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ae81919b864-acfcloneindex-field_69b092b7f83d7\">Intensit\u00e9 moyenne de la douleur APRES TRAITEMENT<\/label><\/div>\n<div class=\"acf-input\">\n<select id=\"acf-field_69ae81919b864-acfcloneindex-field_69b092b7f83d7\" class=\"\" name=\"acf[field_69ae81919b864][acfcloneindex][field_69b092b7f83d7]\" data-ui=\"0\" data-ajax=\"0\" data-multiple=\"0\" data-placeholder=\"Select\" data-allow_null=\"0\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/div>\n<\/div>\n<\/td>\t\t<td class=\"acf-row-handle remove\">\n\t\t\t<a class=\"acf-icon -plus small acf-js-tooltip hide-on-shift\" href=\"#\" data-event=\"add-row\" title=\"Add row\"><\/a>\n\t\t\t<a class=\"acf-icon -duplicate small acf-js-tooltip show-on-shift\" href=\"#\" data-event=\"duplicate-row\" title=\"Duplicate row\"><\/a>\n\t\t\t<a class=\"acf-icon -minus small acf-js-tooltip\" href=\"#\" data-event=\"remove-row\" title=\"Remove row\"><\/a>\n\t\t<\/td>\n\t\t<\/tr>\n\t\t\t\t<\/tbody>\n\t\t\t<\/table>\n\t\t\t\t\t<div class=\"acf-actions\">\n\t\t\t<a class=\"acf-button acf-repeater-add-row button button-primary\" href=\"#\" data-event=\"add-row\">Ajouter un \u00e9pisode th\u00e9rapeutique<\/a>\n\t\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<div class=\"acf-field acf-field-message acf-field-69acad598cd12\" data-name=\"4_coussin_utilise\" data-type=\"message\" data-key=\"field_69acad598cd12\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69acad598cd12\">4_COUSSIN UTILISE<\/label><\/div>\n<div class=\"acf-input\">\n<\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad447ae1b38\" data-name=\"type_coussin\" data-type=\"text\" data-key=\"field_69ad447ae1b38\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ad447ae1b38\">Type de coussin utilis\u00e9<\/label><p class=\"description\">Par exemple : assises statiques : coussins bou\u00e9e, en U, en V,  \u00e9videment coccyx, Coussin en gel ou \u00e0 air, coussin mousse, \u00e9videment coccyx, coussin inclin\u00e9s, Coussin \"genouill\u00e9\" (pour position agenouill\u00e9e) - assises dynamiques : ballon, assise multi articul\u00e9es, ...<\/p><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ad447ae1b38\" name=\"acf[field_69ad447ae1b38]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field-69ad460ee1b39\" data-name=\"marque_coussin\" data-type=\"text\" data-key=\"field_69ad460ee1b39\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ad460ee1b39\">Marque du coussin<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_69ad460ee1b39\" name=\"acf[field_69ad460ee1b39]\"\/><\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-group acf-field-69ad4629e1b3a\" data-name=\"impact_coussin\" data-type=\"group\" data-key=\"field_69ad4629e1b3a\">\n<div class=\"acf-label\">\n<label for=\"acf-field_69ad4629e1b3a\">impact coussin qualit\u00e9 de vie<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-fields -top -border\"><div class=\"acf-field acf-field-radio acf-field-69ad4669e1b3b\" style=\"width:33%;\" data-name=\"impact_coussin_douleur\" data-type=\"radio\" data-key=\"field_69ad4669e1b3b\" data-width=\"33\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-label\">Diminution de la douleur<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ad4629e1b3a][field_69ad4669e1b3b]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-supprimee\" name=\"acf[field_69ad4629e1b3a][field_69ad4669e1b3b]\" value=\"supprimee\" checked=\"checked\"\/>Supprim\u00e9e<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-diminuee\" name=\"acf[field_69ad4629e1b3a][field_69ad4669e1b3b]\" value=\"diminuee\"\/>Tr\u00e8s diminu\u00e9e<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-encore\" name=\"acf[field_69ad4629e1b3a][field_69ad4669e1b3b]\" value=\"encore\"\/>Encore un peu pr\u00e9sente<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad4669e1b3b-aucun\" name=\"acf[field_69ad4629e1b3a][field_69ad4669e1b3b]\" value=\"aucun\"\/>Aucun effet<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-radio acf-field-69ad46d9e1b3c\" style=\"width:33%;\" data-name=\"impact_coussin_assise\" data-type=\"radio\" data-key=\"field_69ad46d9e1b3c\" data-width=\"33\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-label\">Temps d\u2019assise<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ad4629e1b3a][field_69ad46d9e1b3c]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-moins_1h\" name=\"acf[field_69ad4629e1b3a][field_69ad46d9e1b3c]\" value=\"moins_1h\" checked=\"checked\"\/>&lt; 1h<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-1_2h\" name=\"acf[field_69ad4629e1b3a][field_69ad46d9e1b3c]\" value=\"1_2h\"\/>1 \u00e0 2h<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-2_3h\" name=\"acf[field_69ad4629e1b3a][field_69ad46d9e1b3c]\" value=\"2_3h\"\/>2 \u00e0 3h<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_69ad4629e1b3a-field_69ad46d9e1b3c-plus_3h\" name=\"acf[field_69ad4629e1b3a][field_69ad46d9e1b3c]\" value=\"plus_3h\"\/>&gt; 3h<\/label><\/li><\/ul><\/div>\n<\/div>\n<div class=\"acf-field acf-field-checkbox acf-field-69ad4730e1b3d\" style=\"width:33%;\" data-name=\"autonomie_retrouvee\" data-type=\"checkbox\" data-key=\"field_69ad4730e1b3d\" data-width=\"33\">\n<div class=\"acf-label\">\n<label id=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-label\">Autonomie retrouv\u00e9e<\/label><\/div>\n<div class=\"acf-input\">\n<input type=\"hidden\" name=\"acf[field_69ad4629e1b3a][field_69ad4730e1b3d]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-conduite\" name=\"acf[field_69ad4629e1b3a][field_69ad4730e1b3d][]\" value=\"conduite\"\/> conduite voiture<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-restaurant\" name=\"acf[field_69ad4629e1b3a][field_69ad4730e1b3d][]\" value=\"restaurant\"\/> restaurant<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-cinema\" name=\"acf[field_69ad4629e1b3a][field_69ad4730e1b3d][]\" value=\"cinema\"\/> cin\u00e9ma<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_69ad4629e1b3a-field_69ad4730e1b3d-transport\" name=\"acf[field_69ad4629e1b3a][field_69ad4730e1b3d][]\" value=\"transport\"\/> transport en commun<\/label><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div><\/div>\n<\/div>\n<div class=\"acf-field acf-field-text acf-field--validate-email\" style=\"display:none !important;\" data-name=\"_validate_email\" data-type=\"text\" data-key=\"_validate_email\">\n<div class=\"acf-label\">\n<label for=\"acf-_validate_email\">Validate Email<\/label><\/div>\n<div class=\"acf-input\">\n<div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-_validate_email\" name=\"acf[_validate_email]\"\/><\/div><\/div>\n<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"acf-form-submit\">\n\t\t\t\t\t<input type=\"submit\" class=\"acf-button button button-primary button-large\" value=\"Envoyer ma contribution\" \/>\t\t\t\t\t<span class=\"acf-spinner\"><\/span>\t\t\t\t<\/div>\n\t\t\t\t<\/form>\n\t\t\t\n    <\/div>\n\n    <!-- \n      Remplacement provisoire si besoin :\n      Ici viendra soit :\n      - le shortcode\/plugin front utilis\u00e9 pour ACF\n      - soit un formulaire PHP rendu par snippet\n    -->\n  <\/div>\n\n  <!-- NAVIGATION -->\n  <div class=\"bp-bdc-box\" style=\"margin-top:14px;\">\n    <strong>Navigation<\/strong>\n    <p style=\"margin:8px 0 0;\">\n      <a href=\"\/partage-experiences\/membres\/\">\u2190 Retour \u00e0 l\u2019espace membres<\/a><br>\n      <a href=\"\/partage-experiences\/membres\/temoignages\/\">\u2190 Consulter les t\u00e9moignages<\/a><br>\n      <a href=\"\/mon-compte\/\">\u2190 Mon compte<\/a>\n    <\/p>\n  <\/div>\n\n<\/section>\n\n<style>\n  .bp-private-members{\n    max-width:1100px;\n    margin:0 auto;\n    padding:20px 14px;\n  }\n\n  .bp-reliance-hero {\n    padding:18px 16px;\n    border-radius:14px;\n    background:#f3f7fb;\n    border-left:6px solid #2c5b8f;\n    border-top:1px solid #f3f7fb;\n    border-right:1px solid #f3f7fb;\n    border-bottom:1px solid #f3f7fb;\n  }\n\n  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Il ne fournit ni diagnostic, ni conseil, ni recommandation m\u00e9dicale. Votre contribution a pour but de rendre visible une exp\u00e9rience de soin, de prise en charge ou d\u2019adaptation ayant eu un effet positif dans votre parcours. D\u00e9crivez chaque \u00e9pisode [&#8230;]\n","protected":false},"author":6,"featured_media":0,"parent":4321,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"pathologie_secondaire":[],"effet_positif":[],"class_list":["post-4657","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v26.9 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Partager une exp\u00e9rience \u2013 Espace Reliance | Blue Portance<\/title>\n<meta name=\"description\" content=\"Partagez votre exp\u00e9rience de prise en charge ou de traitement ayant eu un effet positif. 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