<div class="row">

	<div class="panel panel-success">
	  <div class="panel-body">
	  	<div class="panel-heading">
	  		<h1 class="panel-title">Please read each question and respond accordingly. For each of the questions below circle only one response.</h1>
	  	</div>
	  	
	  	<div class="input-group">
  			<span class="input-group-addon">Id</span>
  			<input type="string" class="form-control" placeholder="Anonymized Patient id (required)" aria-describedby="basic-addon3" ng-model="formData.patientId" ng-readonly="editFields">
  		</div>
  		<div class="input-group">
  			<span class="input-group-addon">Date</span>
  			<input type="text" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.date" readonly>
  		</div>
	  </div>
	</div>

	<div class="panel panel-default">
	  <div class="panel-heading">
	    <h3 class="panel-title">Would you say your health in general is excellent, very good, good, fair or poor?</h3>
	  </div>
	  <div class="panel-body">
	  	<div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="0">
	      </span>
	      <label class="form-control" >N/A</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="1">
	      </span>
	      <label class="form-control" >Excellent</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth"  value="2">
	      </span>
	      <label class="form-control" >Very good</label>
	    </div>
		<div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth"  value="3">
	      </span>
	      <label class="form-control" >Good</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth"  value="4">
	      </span>
	      <label class="form-control" >Fair</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.generalHealth"  value="5">
	      </span>
	      <label class="form-control" >Poor</label>
	    </div>
	  </div>
	</div>
	<br>
	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Would you say your oral health in general is excellent, very good, good, fair or poor?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="0">
		      </span>
		      <label class="form-control" >N/A</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="1">
		      </span>
		      <label class="form-control" >Excellent</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth"  value="2">
		      </span>
		      <label class="form-control" >Very good</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth"  value="3">
		      </span>
		      <label class="form-control" >Good</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth"  value="4">
		      </span>
		      <label class="form-control" >Fair</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.generalOralHealth"  value="5">
		      </span>
		      <label class="form-control" >Poor</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Have you had pain in the face, jaw, temple, in front of the ear or in the ear in the past month?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.painFaceJawTemple" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.painFaceJawTemple"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">How many years ago did your facial pain begin for the first time?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				<input type="number" class="form-control" aria-describedby="basic-addon1" ng-model="formData.beginPainYears">
				<span class="input-group-addon" id="basic-addon1">Years</span>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">How many months ago did your facial pain begin for the first time?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				<input type="number" class="form-control" aria-describedby="basic-addon1" ng-model="formData.beginPainMonths">
				<span class="input-group-addon" id="basic-addon1">Months</span>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Is your facial pain persistent, recurrent or was it only a one-time problem?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="0">
		      </span>
		      <label class="form-control" >N/A</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="1">
		      </span>
		      <label class="form-control" >Persistent</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime"  value="2">
		      </span>
		      <label class="form-control" >Recurrent</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime"  value="3">
		      </span>
		      <label class="form-control" >One time</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Have you ever gone to a physician, dentist, chiropractor or other health professional for facial ache or pain?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="0">
		      </span>
		      <label class="form-control" >N/A</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="1">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional"  value="2">
		      </span>
		      <label class="form-control" >Last six months</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional"  value="3">
		      </span>
		      <label class="form-control" >More than six months</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">How would you rate your facial pain on a 0 to 10 scale at the present time, that is right now, where 0 is "no pain" and 10 is "pain as bad as could be"?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>


	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the past six months, how intense was your worst pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>


	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the past six months, on the average, how intense was your pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were experiencing pain].</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of facial pain?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				<span class="input-group-addon">Days</span>
  				<input type="number" class="form-control" placeholder="Days" aria-describedby="basic-addon3" ng-model="formData.daysKeptFromUsualActivities">
			</div>
		</div>
	</div>


	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the past six months, how much has facial pain interfered with your daily activities rated on a 0 to 10 scale where 0 is "no interference" and 10 is "unable to carry on any activities"?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the past six months, how much has facial pain changed your ability to take part in recreational, social and family activities where 0 is "no interference " and 10 is "extreme change"?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the past six months, how much has facial pain changed your ability to work including housework) where 0 is "no interference " and 10 is "extreme change"?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
				
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="0">
				</span>
				<label class="form-control" >0</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="1">
				</span>
				<label class="form-control" >1</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="2">
				</span>
				<label class="form-control" >2</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="3">
				</span>
				<label class="form-control" >3</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="4">
				</span>
				<label class="form-control" >4</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="5">
				</span>
				<label class="form-control" >5</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="6">
				</span>
				<label class="form-control" >6</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="7">
				</span>
				<label class="form-control" >7</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="8">
				</span>
				<label class="form-control" >8</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="9">
				</span>
				<label class="form-control" >9</label>

				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="10">
				</span>
				<label class="form-control" >10</label>
		      
		    </div>
		    
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Have you ever had your jaw lock or catch so that it won't open all the way?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.jawLockCatch" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.jawLockCatch"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-info">
		<div class="panel-body">
			<div class="alert alert-info" role="alert">
				If no problem opening all the way continue <a ng-click="goToScroll('question15')" href="">here</a>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Was this limitation in jaw opening severe enough to interfere with your ability to eat?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.jawLockLimitationToEat" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.jawLockLimitationToEat"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default" id="question15">
		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Does your jaw click or pop when you open or close your mouth or when chewing?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawClickChewing" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawClickChewing"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>

		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Does your jaw make a grating or grinding noise when it opens and closes or when chewing?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawGratingGrinding" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawGratingGrinding"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>



		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Have you been told, or do you notice that you grind your teeth or clench your jaw while sleeping at night?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.grindTeethClenchWhileSleeping" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.grindTeethClenchWhileSleeping"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>



		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">During the day, do you grind your teeth or clench your jaw?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.duringDayGrindTeethClenchJaw" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.duringDayGrindTeethClenchJaw"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>

		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Does your jaw ache or feel stiff when you wake up in the morning?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawAcheOrStiffMorning" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.jawAcheOrStiffMorning"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>

		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Do you have noises or ringing in your ears?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.noisesOrRingingEars" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.noisesOrRingingEars"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>

		<div class="panel panel-default">
			<div class="panel-heading">
				<h3 class="panel-title">Does your bite feel uncomfortable or unusual?</h3>
			</div>
			<div class="panel-body">
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.biteUncomfortable" value="1">
			      </span>
			      <label class="form-control" >Yes</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.biteUncomfortable"  value="0">
			      </span>
			      <label class="form-control" >No</label>
			    </div>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Do you have rheumatoid arthritis, lupus, or other systemic arthritic disease?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.systemicArthriticDisease" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.systemicArthriticDisease"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>


	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Do you know of anyone in your family who has had any of these diseases?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.knowAnyoneInFamilyWithDiseases" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.knowAnyoneInFamilyWithDiseases"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Have you had or do you have any swollen or painful joint(s) other than the joints close to your ears (TMJ)?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.swollenJointsCloseToEars" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.swollenJointsCloseToEars"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-info">
		<div class="panel-body">
			<div class="alert alert-info" role="alert">
				If no swollen or painful joints continue <a ng-click="goToScroll('question17a')" href="">here</a>
			</div>
		</div>
	</div>

	

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Is this a persistent pain which you have had for at least one year?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.persistentPainAtLeastOneYear" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.persistentPainAtLeastOneYear"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default" id="question17a">
		<div class="panel-heading">
			<h3 class="panel-title">Have you had a recent injury to your face or jaw?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.recentInjuryJawFace" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.recentInjuryJawFace"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>


	<div class="panel panel-info">
		<div class="panel-body">
			<div class="alert alert-info" role="alert">
				If no recent injuries continue <a ng-click="goToScroll('question18')" href="">here</a>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">Did you have jaw pain before the injury?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.painBeforeInjury" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.painBeforeInjury"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default" id="question18">
		<div class="panel-heading">
			<h3 class="panel-title">During the last six months have you had a problem with headaches or migraines?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.lastSixMonthsProblemsWithHeadachesMigraines" value="1">
		      </span>
		      <label class="form-control" >Yes</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.lastSixMonthsProblemsWithHeadachesMigraines"  value="0">
		      </span>
		      <label class="form-control" >No</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default" id="question18">
		<div class="panel-heading">
			<h3 class="panel-title">What activities does your present jaw problem prevent or limit you from doing?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventChewing">
		      </span>
		      <label class="form-control" >Chewing</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventDrinking">
		      </span>
		      <label class="form-control" >Drinking</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventExercising">
		      </span>
		      <label class="form-control" >Exercising</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventEatingHardFoods">
		      </span>
		      <label class="form-control" >Eating Hard Foods</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventEatingSoftFoods">
		      </span>
		      <label class="form-control" >Eating Soft Foods</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSmilingLaughing">
		      </span>
		      <label class="form-control" >Smiling/laughing</label>
		    </div>

		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSexualActivity">
		      </span>
		      <label class="form-control" >Sexual activity</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventCleaningTeethOrFace">
		      </span>
		      <label class="form-control" >Cleaning teeth or face</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventYawning">
		      </span>
		      <label class="form-control" >Yawning</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSwallowing">
		      </span>
		      <label class="form-control" >Swallowing</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventTalking">
		      </span>
		      <label class="form-control" >Talking</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventHavingUsualFaceAppearance">
		      </span>
		      <label class="form-control" >Having your usual facial appearance</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">In the last month, how much have you been distressed by...</h3>
		</div>
		<div class="panel-body">
			<div class="row">
				<div class="col-md-4">
					<label class="form-control" >Headaches</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Loss of sexual interest or pleasure</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Faintness or dizziness</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Pains in the heart or chest</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling low in energy or slowed down</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Thoughts of death or dying</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Poor appetite</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Crying easily</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Blaming yourself for things</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBlamingYourself" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBlamingYourself" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBlamingYourself" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBlamingYourself" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBlamingYourself" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Pains in the lower back</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainsLowerBack" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainsLowerBack" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainsLowerBack" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainsLowerBack" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainsLowerBack" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling lonely</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingLonely" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingLonely" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingLonely" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingLonely" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingLonely" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling blue</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingBlue" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingBlue" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingBlue" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingBlue" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingBlue" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Worrying too much about things</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedWorryTooMuchAboutThings" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedWorryTooMuchAboutThings" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedWorryTooMuchAboutThings" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedWorryTooMuchAboutThings" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedWorryTooMuchAboutThings" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>


			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling no interest in things</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingNoInterest" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingNoInterest" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingNoInterest" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingNoInterest" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingNoInterest" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>


			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Nausea or upset stomach</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNauseaUpsetStomach" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNauseaUpsetStomach" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNauseaUpsetStomach" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNauseaUpsetStomach" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNauseaUpsetStomach" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Soreness of your muscles</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedMuscleSoreness" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedMuscleSoreness" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedMuscleSoreness" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedMuscleSoreness" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedMuscleSoreness" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Trouble falling asleep</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleFallingAsleep" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleFallingAsleep" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleFallingAsleep" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleFallingAsleep" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleFallingAsleep" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Trouble getting your breath</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleGettingYourBreath" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleGettingYourBreath" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleGettingYourBreath" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleGettingYourBreath" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedTroubleGettingYourBreath" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Hot or cold spells</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHotColdSpells" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHotColdSpells" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHotColdSpells" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHotColdSpells" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHotColdSpells" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Numbness or tingling in parts of your body</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNumbnessOrTingling" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNumbnessOrTingling" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNumbnessOrTingling" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNumbnessOrTingling" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedNumbnessOrTingling" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >A lump in your throat</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLumpInThroat" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLumpInThroat" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLumpInThroat" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLumpInThroat" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLumpInThroat" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling hopeless about the future</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingHopeless" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingHopeless" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingHopeless" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingHopeless" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingHopeless" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling weak in parts of your body</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWeak" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWeak" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWeak" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWeak" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWeak" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Heavy feelings in your arms or legs</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeavyFeelingsArmsLegs" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeavyFeelingsArmsLegs" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeavyFeelingsArmsLegs" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeavyFeelingsArmsLegs" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeavyFeelingsArmsLegs" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Thoughts of ending your life</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughsOfEndingLife" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughsOfEndingLife" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughsOfEndingLife" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughsOfEndingLife" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughsOfEndingLife" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Overeating</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedOvereating" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedOvereating" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedOvereating" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedOvereating" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedOvereating" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Awakening in the early morning</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedAwakeningEarlyMorning" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedAwakeningEarlyMorning" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedAwakeningEarlyMorning" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedAwakeningEarlyMorning" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedAwakeningEarlyMorning" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Sleep that is restless or disturbed </label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedSleepThatIsRestless" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedSleepThatIsRestless" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedSleepThatIsRestless" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedSleepThatIsRestless" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedSleepThatIsRestless" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling everything is an effort</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedEverythingIsEffort" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedEverythingIsEffort" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedEverythingIsEffort" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedEverythingIsEffort" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedEverythingIsEffort" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feelings of worthlessness</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWorthlessness" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWorthlessness" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWorthlessness" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWorthlessness" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingWorthlessness" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feeling of being caught or trapped.</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBeingCaughtTrapped" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBeingCaughtTrapped" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBeingCaughtTrapped" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBeingCaughtTrapped" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedBeingCaughtTrapped" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>

			<div class="row">
			    <div class="col-md-4">
					<label class="form-control" >Feelings of guilt</label>
				</div>
				<div class="col-md-8">
					<div class="input-group">
						
						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingGuilt" value="0">
						</span>
						<label class="form-control" >0</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingGuilt" value="1">
						</span>
						<label class="form-control" >1</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingGuilt" value="2">
						</span>
						<label class="form-control" >2</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingGuilt" value="3">
						</span>
						<label class="form-control" >3</label>

						<span class="input-group-addon">
							<input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFeelingGuilt" value="4">
						</span>
						<label class="form-control" >4</label>
				      
				    </div>
				</div>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">How good a job do you feel you are doing in taking care of your health overall?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall" value="0">
		      </span>
		      <label class="form-control" >N/A</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall" value="1">
		      </span>
		      <label class="form-control" >Excellent</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall"  value="2">
		      </span>
		      <label class="form-control" >Very good</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall"  value="3">
		      </span>
		      <label class="form-control" >Good</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall"  value="4">
		      </span>
		      <label class="form-control" >Fair</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfHealthOverall"  value="5">
		      </span>
		      <label class="form-control" >Poor</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3 class="panel-title">How good a job do you feel you are doing in taking care of your oral health?</h3>
		</div>
		<div class="panel-body">
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth" value="0">
		      </span>
		      <label class="form-control" >N/A</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth" value="1">
		      </span>
		      <label class="form-control" >Excellent</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth"  value="2">
		      </span>
		      <label class="form-control" >Very good</label>
		    </div>
			<div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth"  value="3">
		      </span>
		      <label class="form-control" >Good</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth"  value="4">
		      </span>
		      <label class="form-control" >Fair</label>
		    </div>
		    <div class="input-group">
		      <span class="input-group-addon">
		        <input type="radio" aria-label="..." ng-model="formData.takingCareOfOralHealth"  value="5">
		      </span>
		      <label class="form-control" >Poor</label>
		    </div>
		</div>
	</div>

	<div class="panel panel-default">
	  <div class="panel-heading">
	    <h3 class="panel-title">Do you have pain on the right side of your face, the left side or both sides?</h3>
	  </div>
	  <div class="panel-body">
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.painLocation" value="0">
	      </span>
	      <label class="form-control" >None</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.painLocation"  value="1">
	      </span>
	      <label class="form-control" >Right</label>
	    </div>
		<div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.painLocation"  value="2">
	      </span>
	      <label class="form-control" >Left</label>
	    </div>
	    <div class="input-group">
	      <span class="input-group-addon">
	        <input type="radio" aria-label="..." ng-model="formData.painLocation"  value="3">
	      </span>
	      <label class="form-control" >Both</label>
	    </div>
	  </div>
	</div>
	<br>
	<div class="panel panel-default">
	  <div class="panel-heading">
	    <h3 class="panel-title">Could you point to the areas where you feel pain?</h3>
	  </div>
	  <div class="panel-body">

	  	<div class="col-md-6">
		  	<div class="panel panel-default">
			  <div class="panel-heading">
			    Rigth
			  </div>
			  <div class="panel-body">
			  	<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painRight" value="0">
			      </span>
			      <label class="form-control">None</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painRight"  value="1">
			      </span>
			      <label class="form-control" >Jaw joint</label>
			    </div>
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painRight"  value="2">
			      </span>
			      <label class="form-control" >Muscles</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painRight"  value="3">
			      </span>
			      <label class="form-control" >Both</label>
			    </div>
			  </div>
			</div>
		</div>

		<div class="col-md-6">
			<div class="panel panel-default">
			  <div class="panel-heading">
			    Left
			  </div>
			  <div class="panel-body">
			  	<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painLeft" value="0">
			      </span>
			      <label class="form-control">None</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painLeft"  value="1">
			      </span>
			      <label class="form-control" >Jaw joint</label>
			    </div>
				<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painLeft"  value="2">
			      </span>
			      <label class="form-control" >Muscles</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.painLeft"  value="3">
			      </span>
			      <label class="form-control" >Both</label>
			    </div>
			  </div>
			</div>
		</div>
	  </div>
	</div>

	<div class="panel panel-default">
	  <div class="panel-heading">
	    <h3 class="panel-title">Opening Pattern</h3>
	  </div>
	  <div class="panel-body">
	  	<div class="input-group">
	  		<span class="input-group-addon">
	  			<input type="radio" aria-label="..." ng-model="formData.openingPattern"  value="0">
	  		</span>
	  		<label class="form-control">Straight</label>
	  		<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.openingPattern" value="1">
				</span>
				<label class="form-control">Uncorrected Right lateral deviation</label>
			</div>
		    <span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.openingPattern" value="2">
				</span>
				<label class="form-control">Corrected (S) Right lateral deviation</label>
			</div>
			<div class="input-group">
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.openingPattern" value="3">
				</span>
				<label class="form-control">Uncorrected Left lateral deviation</label>
			</div>
			<div class="input-group">
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.openingPattern" value="4">
				</span>
				<label class="form-control">Corrected (S) Left lateral deviation</label>
			</div>
			<div class="input-group">
				<span class="input-group-addon">
					<input type="radio" aria-label="..." ng-model="formData.openingPattern" value="5">
				</span>
				<label class="form-control">Other</label>
				<input type="text" class="form-control" aria-describedby="basic-addon1" ng-model="formData.openingPatternComments">
			</div>
	  </div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
	    	<h3 class="panel-title">Vertical range motion</h3>
	  	</div>
	  	<div class="panel-body">
	  		<div class="input-group">
	  			<span class="input-group-addon">Unassisted opening without pain</span>
	  			<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.verticalRangeUnassistedWOPain">
	  			<span class="input-group-addon">mm</span>
			</div>
			<div class="input-group">
					<span class="input-group-addon">Maximum unassisted opening</span>
	  			<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.verticalRangeUnassistedMax">
	  			<span class="input-group-addon">mm</span>
			</div>
			<div class="input-group">
				<span class="input-group-addon" >Maximum assisted opening</span>
  			<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.verticalRangeAssistedMax">
  			<span class="input-group-addon">mm</span>
			</div>
			<div class="input-group">
				<span class="input-group-addon" >Vertical incisal overlap</span>
  			<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.verticalRangeIncisalOverlap">
  			<span class="input-group-addon">mm</span>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel panel-default">
			<div class="panel-heading">
		    	<h3 class="panel-title">Joint sounds</h3>
		  	</div>
		  	<div class="panel-body">
		  		<div class="panel panel-default">
					<div class="panel-heading">
				    	<h3 class="panel-title">Opening</h3>
				  	</div>
				  	<div class="panel-body">
				  		<div class="col-md-6">
				  			<div class="panel panel-default">
								  <div class="panel-heading">
								    Rigth
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningRight" value="0">
								      </span>
								      <label class="form-control">None</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningRight"  value="1">
								      </span>
								      <label class="form-control" >Click</label>
								    </div>
									<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningRight"  value="2">
								      </span>
								      <label class="form-control" >Coarse crepitus</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningRight"  value="3">
								      </span>
								      <label class="form-control" >Fine crepitus</label>
								    </div>
								    <div class="input-group">
								    	<span class="input-group-addon">Measurement of Opening Click</span>
							  			<input type="text" class="form-control" placeholder="0.0" ng-model="formData.jointSoundOpeningRightMeasurment">
							  			<span class="input-group-addon">mm</span>
									</div>
							  </div>
							</div>
						</div>
						<div class="col-md-6">
							<div class="panel panel-default">
							  <div class="panel-heading">
							    Left
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningLeft" value="0">
							      </span>
							      <label class="form-control">None</label>
							    </div>
							    <div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningLeft"  value="1">
							      </span>
							      <label class="form-control" >Click</label>
							    </div>
									<div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningLeft"  value="2">
							      </span>
							      <label class="form-control" >Coarse crepitus</label>
							    </div>
							    <div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundOpeningLeft"  value="3">
							      </span>
							      <label class="form-control" >Fine crepitus</label>
							    </div>
							    <div class="input-group">
							    	<span class="input-group-addon">Measurement of Opening Click</span>
						  			<input type="number" class="form-control" placeholder="0.0" ng-model="formData.jointSoundOpeningLeftMeasurement">
						  			<span class="input-group-addon">mm</span>
									</div>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="panel panel-default">
					<div class="panel-heading">
				    	<h3 class="panel-title">Closing</h3>
				  	</div>
				  	<div class="panel-body">
				  		<div class="col-md-6">
				  			<div class="panel panel-default">
								  <div class="panel-heading">
								    Rigth
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingRight" value="0">
								      </span>
								      <label class="form-control">None</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingRight"  value="1">
								      </span>
								      <label class="form-control" >Click</label>
								    </div>
									<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingRight"  value="2">
								      </span>
								      <label class="form-control" >Coarse crepitus</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingRight"  value="3">
								      </span>
								      <label class="form-control" >Fine crepitus</label>
								    </div>
								    <div class="input-group">
								    	<span class="input-group-addon">Measurement of Closing Click</span>
							  			<input type="text" class="form-control" placeholder="0.0" ng-model="formData.jointSoundClosingRightMeasurment">
							  			<span class="input-group-addon">mm</span>
									</div>
							  </div>
							</div>
						</div>
						<div class="col-md-6">
							<div class="panel panel-default">
							  <div class="panel-heading">
							    Left
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingLeft" value="0">
							      </span>
							      <label class="form-control">None</label>
							    </div>
							    <div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingLeft"  value="1">
							      </span>
							      <label class="form-control" >Click</label>
							    </div>
									<div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingLeft"  value="2">
							      </span>
							      <label class="form-control" >Coarse crepitus</label>
							    </div>
							    <div class="input-group">
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundClosingLeft"  value="3">
							      </span>
							      <label class="form-control" >Fine crepitus</label>
							    </div>
							    <div class="input-group">
							    	<span class="input-group-addon">Measurement of Closing Click</span>
						  			<input type="number" class="form-control" placeholder="0.0" ng-model="formData.jointSoundClosingLeftMeasurement">
						  			<span class="input-group-addon">mm</span>
									</div>
								</div>
							</div>
						</div>
					</div>
				</div>
		  	</div>
		</div>
	</div>

	<div class="panel panel-default">
	 	<div class="panel-heading">
	 		<h3 class="panel-title">Excursions</h3>
	 	</div>
	  <div class="panel-body">
	  	<div class="input-group">
	  		<span class="input-group-addon" id="basic-addon3">Right Lateral Excursion</span>
	  		<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.excursionsRightLateral">
	  		<span class="input-group-addon">mm</span>
			</div>
			<div class="input-group">
	  		<span class="input-group-addon" id="basic-addon3">Left Lateral Excursion</span>
	  		<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.excursionsLeftLateral">
	  		<span class="input-group-addon">mm</span>
			</div>
			<div class="input-group">
	  		<span class="input-group-addon" id="basic-addon3">Protrusion</span>
	  		<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.excursionsProtrusion">
	  		<span class="input-group-addon">mm</span>
			</div>

			<div class="panel panel-default">
			 	<div class="panel-heading">
			 		Midline Deviation
			 	</div>
			  <div class="panel-body">
					<div class="input-group">
			  		<span class="input-group-addon" id="basic-addon3">Deviation</span>
			  		<input type="number" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.excursionsMidlineDeviation">
			  		<span class="input-group-addon">mm</span>
					</div>
					<div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.excursionsMidlineDeviationSide"  value="1">
			      </span>
			      <label class="form-control" >Right</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.excursionsMidlineDeviationSide"  value="2">
			      </span>
			      <label class="form-control" >Left</label>
			    </div>
			    <div class="input-group">
			      <span class="input-group-addon">
			        <input type="radio" aria-label="..." ng-model="formData.excursionsMidlineDeviationSide"  value="8">
			      </span>
			      <label class="form-control" >N/A</label>
			    </div>
			  </div>
			</div>
	  </div>
	</div>


	<div class="panel panel-default">
	 	<div class="panel-heading">
	 		<h3 class="panel-title">Joint sounds excursions</h3>
	 	</div>
	  <div class="panel-body">
	  	<div class="col-md-12">
	  		<div class="panel panel-default">
				  <div class="panel-heading">
				    Rigth sounds
				  </div>
				  <div class="panel-body">
				  	<div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Excursion right
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionRight" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionRight"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionRight"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionRight"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>
					  <div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Excursion left
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionLeft" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionLeft"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionLeft"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionLeft"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>

					  <div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Protrusion
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionProtrusion" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionProtrusion"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionProtrusion"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsRightSoundExcursionProtrusion"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>
					</div>
				</div>
	  	</div>
	  	<div class="col-md-12">
	  		<div class="panel panel-default">
				  <div class="panel-heading">
				    Left sounds
				  </div>
				  <div class="panel-body">
				  	<div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Excursion right
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionRight" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionRight"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionRight"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionRight"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>
					  <div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Excursion left
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionLeft" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionLeft"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionLeft"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionLeft"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>

					  <div class="col-md-4">
					  	<div class="panel panel-default">
							  <div class="panel-heading">
							    Protrusion
							  </div>
							  <div class="panel-body">
							  	<div class="input-group">
							  		<label class="form-control">None</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionProtrusion" value="0">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control">Click</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionProtrusion"  value="1">
							      </span>
							    </div>
									<div class="input-group">
										<label class="form-control" >Coarse crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionProtrusion"  value="2">
							      </span>
							    </div>
							    <div class="input-group">
							    	<label class="form-control" >Fine crepitus</label>
							      <span class="input-group-addon">
							        <input type="radio" aria-label="..." ng-model="formData.jointSoundExcursionsLeftSoundExcursionProtrusion"  value="3">
							      </span>
							    </div>
							  </div>
							</div>
					  </div>
					</div>
				</div>
	  	</div>
	  </div>
	</div>

	<div class="panel panel-info">
		<div class="panel-heading">
	    <h3>Directions for next items</h3>
	  </div>
	  <div class="panel-body">
	  	The examiner will be palpating (touching) different areas of your face, head and neck. We would like you to indicate if you do not feel pain or just feel pressure (0), or pain (1-3). Please rate how much pain you feel for each of the palpations according to the scale below. Circle the number that corresponds to the amount of pain you feel. We would like you to make a separate rating for both the right and left palpations.
	  	<br>
			0 = No Pain/Pressure Only 
			<br>
			1 = Mild Pain
			<br>
			2 = Moderate Pain
			<br>
			3 = Severe Pain
	  </div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
			<h3>Extraoral muscle pain with palpation</h3>
		</div>
		<div class="panel-body">
		  	<div class="col-md-6">
			  	<div class="panel panel-default">
			  		<div class="panel-heading">
					    Temporalis
					</div>
					<div class="panel-body">
					  	<div class="col-md-6">
						  	<div class="panel panel-default">
									<div class="panel-heading">
								    Right
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleTemporalisRight"  value="0">
								      </span>
								      <label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleTemporalisRight"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleTemporalisRight"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleTemporalisRight"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
								  </div>
							  </div>
							</div>
							<div class="col-md-6">
						    <div class="panel panel-default">
									<div class="panel-heading">
								    Left
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleRemporalisLeft"  value="0">
								      </span>
								      <label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleRemporalisLeft"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleRemporalisLeft"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleRemporalisLeft"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
								  </div>
								</div>
							</div>
					  	</div>
					</div>
			</div>
			<div class="col-md-6">
				<div class="panel panel-default">
					<div class="panel-heading">
					    Masseter
					</div>
					<div class="panel-body">
					  	<div class="col-md-6">
						  	<div class="panel panel-default">
						  		<div class="panel-heading">
								    Right
								</div>
								<div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterRight"  value="0">
								      </span>
								      <label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterRight"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterRight"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterRight"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
								</div>
							</div>
						</div>
						<div class="col-md-6">
					    	<div class="panel panel-default">
					    		<div class="panel-heading">
					    			Left
					    		</div>
								<div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								  			<input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterLeft"  value="0">
								  		</span>
								  		<label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterLeft"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterLeft"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationExtraoralMuscleMasseterLeft"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
							  	</div>
							</div>
						</div>
					</div>
		  		</div>
			</div>
		</div>
	</div>

	<div class="panel panel-default">
		<div class="panel-heading">
	    <h3>Joint pain with palpation</h3>
	  </div>
	  <div class="panel-body">
	  	<div class="panel panel-default">
				<div class="panel-heading">
			    Lateral pole "outside"
			  </div>
			  <div class="panel-body">
			  	<div class="col-md-6">
				  	<div class="panel panel-default">
							<div class="panel-heading">
						    Right
						  </div>
						  <div class="panel-body">
						  	<div class="input-group">
						  		<span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleRight"  value="0">
						      </span>
						      <label class="form-control" >0</label>
						  	</div>
					     	<div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleRight"  value="1">
						      </span>
						      <label class="form-control" >1</label>
					    	</div>
					    	<div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleRight"  value="2">
						      </span>
						      <label class="form-control" >2</label>
						    </div>
						    <div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleRight"  value="3">
						      </span>
						      <label class="form-control" >3</label>
						    </div>
						  </div>
					  </div>
					</div>
					<div class="col-md-6">
				    <div class="panel panel-default">
							<div class="panel-heading">
						    Left
						  </div>
						  <div class="panel-body">
						  	<div class="input-group">
						  		<span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleLeft"  value="0">
						      </span>
						      <label class="form-control" >0</label>
						  	</div>
					     	<div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleLeft"  value="1">
						      </span>
						      <label class="form-control" >1</label>
					    	</div>
					    	<div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleLeft"  value="2">
						      </span>
						      <label class="form-control" >2</label>
						    </div>
						    <div class="input-group">
						      <span class="input-group-addon">
						        <input type="radio" aria-label="..." ng-model="formData.palpationJointLateralPoleLeft"  value="3">
						      </span>
						      <label class="form-control" >3</label>
						    </div>
						  </div>
						</div>
					</div>
			  </div>
			</div>
		</div>
	</div>


	<div class="panel panel-default">
		<div class="panel-heading">
			<h3>Intraoral muscle pain with palpation</h3>
		</div>
		<div class="panel-body">
		  	<div class="col-md-6">
			  	<div class="panel panel-default">
						<div class="panel-heading">
					    Lateral pterygoid area "Behind upper molars"
					  </div>
					  <div class="panel-body">
					  	<div class="col-md-6">
						  	<div class="panel panel-default">
									<div class="panel-heading">
								    Right
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidRight"  value="0">
								      </span>
								      <label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidRight"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidRight"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidRight"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
								  </div>
							  </div>
							</div>
							<div class="col-md-6">
						    <div class="panel panel-default">
									<div class="panel-heading">
								    Left
								  </div>
								  <div class="panel-body">
								  	<div class="input-group">
								  		<span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidLeft"  value="0">
								      </span>
								      <label class="form-control" >0</label>
								  	</div>
							     	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidLeft"  value="1">
								      </span>
								      <label class="form-control" >1</label>
							    	</div>
							    	<div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidLeft"  value="2">
								      </span>
								      <label class="form-control" >2</label>
								    </div>
								    <div class="input-group">
								      <span class="input-group-addon">
								        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleLateralPterygoidLeft"  value="3">
								      </span>
								      <label class="form-control" >3</label>
								    </div>
								  </div>
								</div>
							</div>
					  </div>
					</div>
				</div>
				<div class="col-md-6">
					<div class="panel panel-default">
							<div class="panel-heading">
								Tendon of temporalis "Tendon"
							</div>
							  <div class="panel-body">
							  	<div class="col-md-6">
								  	<div class="panel panel-default">
											<div class="panel-heading">
										    Right
										  </div>
										  <div class="panel-body">
										  	<div class="input-group">
										  		<span class="input-group-addon">
										        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisRight"  value="0">
										      </span>
										      <label class="form-control" >0</label>
										  	</div>
									     	<div class="input-group">
										      <span class="input-group-addon">
										        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisRight"  value="1">
										      </span>
										      <label class="form-control" >1</label>
									    	</div>
									    	<div class="input-group">
										      <span class="input-group-addon">
										        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisRight"  value="2">
										      </span>
										      <label class="form-control" >2</label>
										    </div>
										    <div class="input-group">
										      <span class="input-group-addon">
										        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisRight"  value="3">
										      </span>
										      <label class="form-control" >3</label>
										    </div>
										  </div>
									  </div>
									</div>
									<div class="col-md-6">
									    <div class="panel panel-default">
									    	<div class="panel-heading">
											    Left
											</div>
											  <div class="panel-body">
											  	<div class="input-group">
											  		<span class="input-group-addon">
											        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisLeft"  value="0">
											      </span>
											      <label class="form-control" >0</label>
											  	</div>
										     	<div class="input-group">
											      <span class="input-group-addon">
											        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisLeft"  value="1">
											      </span>
											      <label class="form-control" >1</label>
										    	</div>
										    	<div class="input-group">
											      <span class="input-group-addon">
											        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisLeft"  value="2">
											      </span>
											      <label class="form-control" >2</label>
											    </div>
											    <div class="input-group">
											      <span class="input-group-addon">
											        <input type="radio" aria-label="..." ng-model="formData.palpationIntraoralMuscleTendonTemporalisLeft"  value="3">
											      </span>
											      <label class="form-control" >3</label>
											    </div>
									  		</div>
										</div>
								</div>
						  </div>
					</div>
				</div>
		</div>
	</div>
</div>