{"id":19706,"date":"2023-02-13T16:53:12","date_gmt":"2023-02-13T16:53:12","guid":{"rendered":"https:\/\/support.orthopedics.moveup.care\/formulieren\/stuur-opt-out-enquete-naar-patient\/"},"modified":"2023-02-13T16:53:12","modified_gmt":"2023-02-13T16:53:12","slug":"stuur-opt-out-enquete-naar-patient","status":"publish","type":"page","link":"https:\/\/support.orthopedics.moveup.care\/nl\/formulieren\/stuur-opt-out-enquete-naar-patient\/","title":{"rendered":"Stuur opt-out enqu\u00eate naar pati\u00ebnt"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_52' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Send opt-out survey to patient<\/h2>\n                            <span class='gform_description'><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_52'  action='\/nl\/wp-json\/wp\/v2\/pages\/19706' ><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeslIceAAAAAPBU16SFCLen5RDeLfftiJdUobau' data-tabindex='0'><input id=\"input_269100219d024f790908b77bdced741a\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_269100219d024f790908b77bdced741a\" value=\"\"\/><\/div>\n                        <div class='gform_body gform-body'><div id='gform_fields_52' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_52_4\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_4\"><label class='gfield_label' for='input_52_4' >Patient name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_52_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_52_1\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_1\"><label class='gfield_label' for='input_52_1' >Patient number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_1' id='input_52_1' type='text'    value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_52_3\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_3\"><label class='gfield_label' for='input_52_3' >Patient email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_52_3' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_52_10\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_10\"><label class='gfield_label' for='input_52_10' >Copy-paste the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_52_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_52_5\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_5\"><legend class='gfield_label'  >Language patient (email will be sent in this language)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_52_5'>\n\t\t\t<div class='gchoice gchoice_52_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Dutch'  id='choice_52_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_5_0' id='label_52_5_0'>Dutch<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='French'  id='choice_52_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_5_1' id='label_52_5_1'>French<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='English'  id='choice_52_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_5_2' id='label_52_5_2'>English<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_52_9\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_9\"><legend class='gfield_label gfield_label_before_complex'  >Categorisation reason given by PT<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_52_9'><div class='gchoice gchoice_52_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Complexity'  id='choice_52_9_1'   aria-describedby=\"gfield_description_52_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_1' id='label_52_9_1'>Complexity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Unknown'  id='choice_52_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_2' id='label_52_9_2'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Co-morbidity'  id='choice_52_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_3' id='label_52_9_3'>Co-morbidity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Complication'  id='choice_52_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_4' id='label_52_9_4'>Complication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Complication - Swelling (lymphe drainage)'  id='choice_52_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_5' id='label_52_9_5'>Complication &#8211; Swelling (lymphe drainage)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Physical session'  id='choice_52_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_6' id='label_52_9_6'>Physical session<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Non-responsive'  id='choice_52_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_7' id='label_52_9_7'>Non-responsive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Digital analphabete'  id='choice_52_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_8' id='label_52_9_8'>Digital analphabete<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Not given by PT...asked via Jira or email'  id='choice_52_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_9' id='label_52_9_9'>Not given by PT&#8230;asked via Jira or email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='On advice of a HCP'  id='choice_52_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_11' id='label_52_9_11'>On advice of a HCP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Not happy with follow-up'  id='choice_52_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_12' id='label_52_9_12'>Not happy with follow-up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='Surgery postponed\/cancelled'  id='choice_52_9_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_13' id='label_52_9_13'>Surgery postponed\/cancelled<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_52_9_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.14' type='checkbox'  value='OTHER'  id='choice_52_9_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_9_14' id='label_52_9_14'>OTHER<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_52_9'>To add a categorisation reason: <a href=\"https:\/\/support.orthopedics.moveup.care\/wp-admin\/admin.php?page=gf_edit_forms&#038;id=52&#038;gf_ajax_save=sn4amyecv\" target=\"_blank\">Link to edit the survey<\/a>.\nManual to add a category in <a href=\"https:\/\/moveup.atlassian.net\/l\/cp\/wd593fs4\" target=\"_blank\">https:\/\/moveup.atlassian.net\/l\/cp\/wd593fs4<\/a>\nIf you want to download an excel with all category reasons: there is an export function in the Forms menu of WP<\/div><\/fieldset><fieldset id=\"field_52_6\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_6\"><legend class='gfield_label'  >Preop or postop opt-out?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_52_6'>\n\t\t\t<div class='gchoice gchoice_52_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Preop'  id='choice_52_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_6_0' id='label_52_6_0'>Preop<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Postop'  id='choice_52_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_6_1' id='label_52_6_1'>Postop<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_52_12\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_12\"><label class='gfield_label' for='input_52_12' >How many days postop?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_52_12' type='text'    value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_52_8\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_8\"><legend class='gfield_label'  >App installed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_52_8'>\n\t\t\t<div class='gchoice gchoice_52_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_52_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_8_0' id='label_52_8_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_52_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_8_1' id='label_52_8_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_52_7\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_7\"><legend class='gfield_label'  >Any activity of the patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_52_7'>\n\t\t\t<div class='gchoice gchoice_52_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='None whatsoever'  id='choice_52_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_7_0' id='label_52_7_0'>None whatsoever<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Barely (for example one chat message)'  id='choice_52_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_7_1' id='label_52_7_1'>Barely (for example one chat message)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Normal activity'  id='choice_52_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_7_2' id='label_52_7_2'>Normal activity<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_52_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gf_other_choice'  id='choice_52_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_52_7_3' id='label_52_7_3'>Anders<\/label><br \/><input id='input_52_7_other' name='input_7_other' type='text' value='Anders' aria-label='Andere keuze, gelieve te specificeren'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_52_11\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_11\"><legend class='gfield_label gfield_label_before_complex'  >Remove satisfaction @stop survey<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_52_11'><div class='gchoice gchoice_52_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Done'  id='choice_52_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_52_11_1' id='label_52_11_1'>Done<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_52_15\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_15\"><legend class='gfield_label'  >Place a thumb-up symbol in Jira so you are sure you did it already for this patient.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_52_15'>\n\t\t\t<div class='gchoice gchoice_52_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Done'  id='choice_52_15_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_52_15\"   \/>\n\t\t\t\t\t<label for='choice_52_15_0' id='label_52_15_0'>Done<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_52_15'><img decoding=\"async\" src=\"https:\/\/support.orthopedics.moveup.care\/wp-content\/uploads\/2022\/10\/2022-10-26_13-32-54.jpg\" width=\"400\" >\n<\/div><\/fieldset><div id=\"field_52_13\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_13\"><label class='gfield_label' for='input_52_13' >Optional remark<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_52_13' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_52_16\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_52_16\">To change content of email: <a href=\"https:\/\/support.orthopedics.moveup.care\/wp-admin\/admin.php?page=gf_edit_forms&#038;view=settings&#038;subview=notification&#038;id=52\" target=\"_blank\">https:\/\/support.orthopedics.moveup.care\/wp-admin\/admin.php?page=gf_edit_forms&#038;view=settings&#038;subview=notification&#038;id=52<\/a><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_52' class='gform_button button' value='Completed'  onclick='if(window[\"gf_submitting_52\"]){return false;}  window[\"gf_submitting_52\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_52\"]){return false;} window[\"gf_submitting_52\"]=true;  jQuery(\"#gform_52\").trigger(\"submit\",[true]); }' \/> \n     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