{"id":233,"date":"2023-09-26T20:59:36","date_gmt":"2023-09-26T20:59:36","guid":{"rendered":"http:\/\/bivc19vac.dk\/?page_id=233"},"modified":"2024-02-28T20:06:01","modified_gmt":"2024-02-28T20:06:01","slug":"bliv-medlem-formular","status":"publish","type":"page","link":"https:\/\/bivc19vac.dk\/en\/bliv-medlem-formular\/","title":{"rendered":"Become a member \u2013 form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\">\n<style>\n.form__group .checkbox-list {\n   \n    border: 1px solid #ccc; \n}\n\n.form__group .checkbox-list label {\n    display: block;\n    padding: 5px 10px;\n    border-bottom: 1px solid #eee;\n    margin: 0;\n}\n\n.form__group .checkbox-list label:last-child {\n    border-bottom: none; \n}\n<\/style>\n\n<form action=\"https:\/\/portal.foreningsadministrator.dk\/tilmeld.php\" method=\"post\" enctype=\"multipart\/form-data\" autocomplete=\"off\" id=\"foadmembersignupform\">\n\t<div class=\"form__group\">\n\t\t<label>Member type<\/label>\n\t\t<select name=\"FOADMETY\">\n\t\t\t<option value=\"62\">Side effect affected<\/option>\n\t\t\t<option value=\"63\">Relatives of the person affected by the side effect<\/option>\n\t\t\t<option value=\"64\">Sponsor\/support<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>First name<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberFirstname\" class=\"FAVALIDATE FAVALIDATENAME\" value=\"\" id=\"FOAD_FIRSTNAME\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_FIRSTNAME_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Middle name<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberMiddlename\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Surname<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberLastname\" class=\"FAVALIDATE FAVALIDATENAME\" value=\"\" id=\"FOAD_LASTNAME\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_LASTNAME_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Address<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberAdress\" class=\"FAVALIDATE FAVALIDATENAME\" value=\"\" id=\"FOAD_ADDRESS\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_ADDRESS_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Postal code<\/label>\n\t\t<input type=\"text\" size=\"4\" maxlength=\"4\" name=\"MemberZip\" class=\"FAVALIDATE FAVALIDATEZIP\" value=\"\" id=\"FOAD_ZIP\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_ZIP_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Town<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberCity\" class=\"FAVALIDATE FAVALIDATENAME\" value=\"\" id=\"FOAD_CITY\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_CITY_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Email<\/label>\n\t\t<input type=\"text\" size=\"25\" maxlength=\"100\" name=\"MemberEmail\" class=\"FAVALIDATE FAVALIDATEEMAIL\" value=\"\" id=\"FOAD_EMAIL\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_EMAIL_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Phone no.<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"8\" name=\"MemberPhone\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Mobile no.<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"8\" name=\"MemberMobile\" class=\"FAVALIDATE FAVALIDATEPHONE\" value=\"\" id=\"FOAD_MOBILE\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_MOBILE_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Birthday<\/label>\n\t\t<input type=\"text\" size=\"10\" maxlength=\"10\" name=\"MemberBirth\" class=\"FAVALIDATE FAVALIDATEDATE\" value=\"\" id=\"FOAD_BIRTH\" onkeyup=\"foadInputValidate();\"><span id=\"FOAD_BIRTH_HIGHLIGHT\" style=\"font-size: 18px; color: #FF0000;\"><\/span> (dd.mm.yyyy) \n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Sex<\/label>\n\t\t<select name=\"MemberSex\">\n\t\t\t<option value=\"1\">Man<\/option>\n\t\t\t<option value=\"2\">Woman<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Number of connectors<\/label>\n\t\t<select name=\"MemberExtra1\">\n\t\t\t<option>1<\/option>\n\t\t\t<option>2<\/option>\n\t\t\t<option>3<\/option>\n\t\t\t<option>4<\/option>\n\t\t\t<option>5<\/option>\n\t\t\t<option>6<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>1st connector<\/label>\n\t\t<select name=\"MemberExtra2\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Astra Zenica<\/option>\n\t\t\t<option>Johnson<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 1<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra13\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>2nd connector<\/label>\n\t\t<select name=\"MemberExtra3\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Astra Zenica<\/option>\n\t\t\t<option>Johnson<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 2<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra14\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>3rd connector<\/label>\n\n\t\t<select name=\"MemberExtra4\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 3<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra15\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>4th connector<\/label>\n\t\t<select name=\"MemberExtra5\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 4<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra16\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>5th connector<\/label>\n\t\t<select name=\"MemberExtra6\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 5<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra17\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>6th connector<\/label>\n\t\t<select name=\"MemberExtra7\">\n\t\t\t<option>Not selected<\/option>\n\t\t\t<option>Pfizer<\/option>\n\t\t\t<option>Modern<\/option>\n\t\t\t<option>Other<\/option>\n\t\t<\/select>\n\t<\/div>\n\t<div class=\"form__group\">\n\t\t<label>Batch no. for vaccine 18<\/label>\n\t\t<input type=\"text\" size=\"8\" maxlength=\"20\" name=\"MemberExtra18\" value=\"\">\n\t<\/div>\n\t<div class=\"form__group\">\n    <label>Side effects<\/label>\n    <div style=\"height: 300px; overflow-y: auto;\" class=\"checkbox-list\">\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hovedpine, migr\u00e6ne, anfald af stik og jag\">Headaches, migraines, attacks of pins and needles<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hjernet\u00e5ge\">Brain fog<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Tryk i hovedet, propper i \u00f8rerne\">Pressure in the head, stuffiness in the ears<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Svimmelhed, vertigo\">Dizziness, vertigo<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kvalme\">Nausea<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"H\u00f8retab\">Hearing loss<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Tinnitus\">Tinnitus<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lydsensitiv\">Sound sensitive<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lyssensitiv\">Light-sensitive<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hypersensitivitet\">Hypersensitivity<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Synsforstyrrelser herunder sl\u00f8ret syn, dobbeltsyn, t\u00f8rre \u00f8jne, slim i \u00f8jnene\">Visual disturbances including blurred vision, double vision, dry eyes, mucus in the eyes<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Myastenia gravis\">Myasthenia gravis<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Koncentrationsproblemer\">Concentration problems<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hukommelsesproblemer\">Memory problems<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Blackouts m\/u behandling med epilepsimedicin\">Blackouts with\/without treatment with epilepsy medication<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"H\u00f8j puls\/takyardi\">High heart rate\/tachycardia<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lav puls\/bradykardi\">Low heart rate\/bradycardia<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Forh\u00f8jet blodtryk\">High blood pressure<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lavt blodtryk\">Low blood pressure<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Blodpropper\">Blood clots<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"VITT-syndrom\">VITT syndrome<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hjernebl\u00f8dning\">Brain hemorrhage<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Nethindel\u00f8sning p\u00e5 begge \u00f8jne\">Retinal detachment in both eyes<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"H\u00e5rtab\">Hair loss<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Udsl\u00e6t, n\u00e6ldefeber, eksem, fortrykket hud i armhulerne\">Rash, hives, eczema, cracked skin in the armpits<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Anafylaktisk shock\">Anaphylactic shock<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Nyopst\u00e5et overf\u00f8lsomhed\/allergier (f\u00f8devarer, sollys mv.)\">Newly emerged hypersensitivity\/allergies (food, sunlight, etc.)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kl\u00f8ende hud\">Itchy skin<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Helvedesild\">Shingles<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Marmoreringer p\u00e5 ben\/arme (hvid eller bl\u00e5)\">Marbling on legs\/arms (white or blue)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Blister i munden, burning mouth syndrome, udt\u00f8rrede slimhinder i munden\">Blisters in the mouth, burning mouth syndrome, dried mucous membranes in the mouth<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Bl\u00e5 m\u00e6rker\/blodansamlinger\">Bruises\/blood clots<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Tr\u00e6thed\/fatigue\">Fatigue<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Energiforladthed\">Energy dependence<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"S\u00f8vnproblemer\">Sleep problems<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Menstruationsforstyrrelser\/menstruationsstop\">Menstrual disorders\/menstrual cessation<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Mavesmerter, mavekramper\">Stomach pain, stomach cramps<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Mavesyre, maves\u00e5r, spiser\u00f8rsbrok\">Heartburn, stomach ulcers, hiatal hernia<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Tarmproblemer (diarr\u00e9, colitis, forstoppelse mv.)\">Intestinal problems (diarrhea, colitis, constipation, etc.)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Langvarig feber\">Prolonged fever<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"F\u00f8leforstyrrelser\">Emotional disorders<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Fibromyalgi\">Fibromyalgia<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Guillain-Barr\u00e9 syndrom\">Guillain-Barr\u00e9 syndrome<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Nervesmerter, nerve zaps (stik og jag)\">Nerve pain, nerve zaps<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Ledsmerter, \u201dknuderosen\u201d\">Joint pain, \u201cknotty rosacea\u201d<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Muskelsmerter\">Muscle pain<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Muskelspasmer, muskelkramper, tics (arme, ben, t\u00e6er, \u00f8jne mv.)\">Muscle spasms, muscle cramps, tics (arms, legs, toes, eyes, etc.)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Muskell\u00e5sning, muskelsp\u00e6ndinger\">Muscle locking, muscle tension<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kropsrystelser, rystende h\u00e6nder, ben mv.\">Body tremors, shaking hands, legs, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lammelser (ansigt), f\u00f8lelsesl\u00f8shed omkring \u00f8jnene\">Paralysis (face), numbness around the eyes<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lammelser (krop)\">Paralysis (body)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Myokarditis\">Myocarditis<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Perikarditis\">Pericarditis<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hjertesvigt\">Heart failure<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hjerterytmeforstyrrelser\">Heart rhythm disorders<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"For stort hjerte\">Too big a heart<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Brystsmerter\">Chest pain<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Nedsat lungefunktion\">Decreased lung function<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"\u00c5nden\u00f8d\">Shortness of breath<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Astma\">Asthma<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hoste (langvarig, kronisk)\">Cough (long-lasting, chronic)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Lav iltning af blodet\">Low blood oxygenation<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Voldsomt fald i blodpladeantal\">Severe drop in platelet count<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hyperinflammation\">Hyperinflammation<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Gigtsygdomme (psoreasisgigt, urinsyregigt, leddegigt, muskelgigt mv.)\">Arthritis (psoriatic arthritis, gout, rheumatoid arthritis, muscular arthritis, etc.)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kronisk autoimmun hepatitis\">Chronic autoimmune hepatitis<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Bet\u00e6ndte s\u00e5r over hele kroppen\">Inflamed wounds all over the body<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Infektioner i \u00f8jenl\u00e5gene\">Eyelid infections<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Reaktivering af tidligere inflammationsskader og allergier\">Reactivation of previous inflammation damage and allergies<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Negle der riller, flosser, bliver m\u00e6rkelige\">Nails that groove, flake, become strange<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Covid-t\u00e6er\">Covid toes<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"POTS (diagnosticeret)\">POTS (diagnosed)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"ME (diagnosticeret)\">ME (diagnosed)<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Post exertional malaise\/sygdomsforv\u00e6rring efter aktivitet.\">Post-exertional malaise\/exacerbation of illness after activity.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Nedsat immunforsvar\">Reduced immune system<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Overaktivering af immunforsvaret\">Overactivation of the immune system<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Hyppige infektioner\/smitte m. influenza, bl\u00e6re-\/bihule-\/halsbet\u00e6ndelser mv.\">Frequent infections\/contagions including influenza, bladder\/sinus\/throat infections, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kroppens kulde-\/varmeregulering i stykker\">The body&#039;s cold\/heat regulation is broken<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Aseptisk avaskul\u00e6r nekrose med tandtab i tidligere sunde t\u00e6nder\">Aseptic avascular necrosis with tooth loss in previously healthy teeth<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Kronisk inflammation i k\u00e6bev\u00e6v\">Chronic inflammation of jaw tissue<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Smerter i k\u00e6be og t\u00e6nder\">Pain in the jaw and teeth<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Vener der dilaterer efter fysisk\/mental\/social aktivitet\">Veins that dilate after physical\/mental\/social activity<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Br\u00e6ndende fornemmelse i huden, hovedbund, arme mv.\">Burning sensation in the skin, scalp, arms, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Forandringer i hormonsystemet, hedeture\">Changes in the hormonal system, hot flashes<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Stofskifteproblemer, uforklarlig v\u00e6gt\u00f8gning\">Metabolic problems, unexplained weight gain<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Balanceproblemer, tab af reflekser i benene, tab af f\u00f8rlighed\">Balance problems, loss of reflexes in the legs, loss of mobility<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"P\u00e5vist M-komponent\">Detected M component<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Depression, angst mv.\">Depression, anxiety, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Ingen stresstolerance\">No stress tolerance<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"H\u00e6velser af hals, ansigt, l\u00e6ber, lymfekirtler, ben, f\u00f8dder mv.\">Swelling of the neck, face, lips, lymph glands, legs, feet, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Raunards syndrom, d\u00e5rlig blodtilf\u00f8rsel, bl\u00e5sp\u00e6ttet, kolde fingre\/f\u00f8dder, hvide fingre, springfingre, stive fingre\">Raunard&#039;s syndrome, poor blood supply, bluish discoloration, cold fingers\/feet, white fingers, club fingers, stiff fingers<\/label>\n\t\t<label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Muskelsvaghed\/nedsat kraft i h\u00e6nder, arme, ben mv.\">Muscle weakness\/reduced strength in hands, arms, legs, etc.<\/label>\n        <label><input type=\"checkbox\" name=\"MemberExtra10[]\" value=\"Frossen skulder, skulderinflammation, skuldersmerter mv. 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