body{
  background: url("../images/ortho_purple_bg.jpg");
  background-repeat: repeat;
  background-size: 125px 125px;
}
#form_logo{
  margin: auto;
  display: block;
  z-index: 0;
  postion: relative;
}
input{
  background: transparent;
}
.form_default{
  background: url("../images/ortho_purple_bg.jpg");
  background-repeat: repeat;
  background-size: 125px 125px;
}
.bold_text{
  color: #3e4a88;
  font-weight: bold;
  font-size: 120%;
}
.text_center{
  text-align: center;
  width: 100%;
  display: block;
}
.box{
  padding: 5px;
  box-sizing: border-box;
  border-top: 10px solid #6e4d90;
  border-right: 10px solid #563e88;
  z-index: 10;
  position: relative;
  background: #fff;
}
.box_header{
  width: 100%;
  background: #8467a6;
  color: #fff;
  text-align: center;
  font-size: 120%;
  font-weight: bold;
  margin: -5px -5px 5px;
  padding: 5px;
}
.box_number{
  background: #eedc37;
  font-size: 250%;
  font-weight: bold;
  position: absolute;
  padding: 0 10px;
  border-radius: 20px;
  top: -20px;
  left: 0;
  color: #3e4282;
  box-shadow: #FFA500 3px 2px 0px 0px;
  border: 2px solid #FFA500;
  text-shadow:-1px -1px 0 #7978b4,1px -1px 0 #7978b4,-1px 1px 0 #7978b4,1px 1px 0 #7978b4;
}
.box_half{
  width: 48%;
  margin: 25px 1% 0;
  float: left;
}
.box_full{
  width: 98%;
  float: left;
  margin: 25px 1% 0;
}
.box_group_half{
  width: 48%;
  float: left;
  margin: 0 1%;
}
.box_group_half .box_full{
  width: 100%;
  float: left;
  margin: 25px 0 0;
}
.box_full .box_half{
  margin: 0 1%;
}
.orange_group{
  background: #edc370;
  margin: 5px -5px -5px;
  padding: 5px;
  overflow: hidden;
}
.yes_no_half {
  width: 48%;
  margin: 0 1%;
  float: left;
}
.box_group_half .box_full.random_box{
  margin: 10px 0 0;
}
.random_box{
  padding: 5px;
  background: #edc370;
  border: 3px solid #563e88;
  box-sizing: border-box;
  margin: 10px 0 0;
}
#top_boxes{
  margin: -50px 0 0 0;
}
input[name="question_1"]{
  width: 25%;
}
input[name="question_2"]{
  width: 39%;
}
input[name="question_3"],#last_name{
  width: 33%;
}
input[name="question_4"],#first_name{
  width: 32%;
}
input[name="question_5"],#middle_name{
  width: 11%;
}
#last_name,#first_name,#middle_name{
  display: inline-block;
  font-size: 80%;
}
#last_name{
  margin-left: 81px;
}
input[name="question_6"]{
  width: 10%;
}
input[name="question_7"]{
  width: 10%;
}
input[name="question_8"]{
  width: 18%;
}
input[name="question_9"]{
  width: 10%;
}
input[name="question_11"]{
  width: 63%;
}
input[name="question_12"]{
  width: 14%;
}
input[name="question_13"]{
  width: 75.5%;
}
input[name="question_14"]{
  width: 15%;
}
input[name="question_15"]{
  width: 58.5%;
}
input[name="question_16"]{
  width: 67%;
}
input[name="question_17"],input[name="question_23"],input[name="question_170"],.city{
  width: 53%;
}
input[name="question_18"],input[name="question_24"],input[name="question_171"],.state{
  width: 15%;
}
input[name="question_19"],input[name="question_25"],input[name="question_172"],.zip{
  width: 27%;
}
.street_address{
  font-size: 80%;
  float: right;
  margin: 0 10px 0 0;
}
.city,.state,.zip{
  font-size: 80%;
  display: inline-block;
}
input[name="question_20"]{
  width: 44%;
}
input[name="question_21"]{
  width: 31%;
}
input[name="question_22"]{
  width: 77.5%;
}
input[name="question_27"]{
  width: 44%;
}
input[name="question_28"]{
  width: 15%;
}
input[name="question_29"]{
  width: 28.5%;
}
input[name="question_30"]{
  width: 34.5%;
}
input[name="question_31"]{
  width: 15%;
}
input[name="question_32"]{
  width: 28%;
}
input[name="question_33"]{
  width: 34.5%;
}
input[name="question_34"]{
  width: 28%;
}
input[name="question_35"]{
  width: 10%;
}
input[name="question_36"]{
  width: 18.5%;
}
input[name="question_37"]{
  width: 8%;
}
input[name="question_38"]{
  width: 89.5%;
}
input[name="question_39"]{
  width: 8.5%;
}
input[name="question_40"]{
  width: 21.5%;
}
input[name="question_41"]{
  width: 8%;
}
input[name="question_42"]{
  width: 8.5%;
}
input[name="question_43"]{
  width: 20.5%;
}
input[name="question_44"]{
  width: 40.5%;
}
input[name="question_45"]{
  width: 34.5%;
}
input[name="question_47"]{
  width: 48%;
}
input[name="question_48"]{
  width: 58%;
}
input[name="question_49"]{
  width: 98.5%;
}
input[name="question_50"]{
  width: 76.5%;
}
input[name="question_51"]{
  width: 77.5%;
}
.marital_status label{
  width: 70px;
  float: left;
}
.marital_status input{
  width: 20px;
  float: left;
}
input[name="question_54"]{
  width: 36%;
}
input[name="question_55"]{
  width: 10%;
}
input[name="question_56"]{
  width: 10%;
}
input[name="question_57"]{
  width: 13%;
}
input[name="question_58"]{
  width: 77.5%;
}
input[name="question_59"]{
  width: 8.5%;
}
input[name="question_60"]{
  width: 27%;
}
input[name="question_61"]{
  width: 8.5%;
}
input[name="question_62"]{
  width: 27%;
}
input[name="question_63"]{
  width: 35.5%;
}
input[name="question_64"]{
  width: 8.5%;
}
input[name="question_65"]{
  width: 27%;
}
input[name="question_66"]{
  width: 40.5%;
}
input[name="question_67"]{
  width: 41%;
}
input[name="question_69"]{
  width: 36%;
}
input[name="question_70"]{
  width: 10%;
}
input[name="question_71"]{
  width: 10%;
}
input[name="question_72"]{
  width: 13%;
}
input[name="question_73"]{
  width: 77.5%;
}
input[name="question_74"]{
  width: 8.5%;
}
input[name="question_75"]{
  width: 27%;
}
input[name="question_76"]{
  width: 8.5%;
}
input[name="question_77"]{
  width: 27%;
}
input[name="question_78"]{
  width: 35.5%;
}
input[name="question_79"]{
  width: 8.5%;
}
input[name="question_80"]{
  width: 27%;
}
input[name="question_81"]{
  width: 40.5%;
}
input[name="question_82"]{
  width: 41%;
}
input[name="question_84"]{
  width: 70%;
}
input[name="question_85"]{
  width: 67%;
}
input[name="question_86"]{
  width: 10%;
}
input[name="question_87"]{
  width: 55.5%;
}
input[name="question_88"]{
  width: 54.5%;
}
input[name="question_89"]{
  width: 68%;
}
input[name="question_90"]{
  width: 67%;
}
input[name="question_91"]{
  width: 8%;
}
input[name="question_92"]{
  width: 8%;
}
input[name="question_93"]{
  width: 10%;
}
input[name="question_94"]{
  width: 25.5%;
}
input[name="question_95"]{
  width: 65%;
}
input[name="question_96"]{
  width: 70%;
}
input[name="question_98"]{
  width: 70%;
}
input[name="question_99"]{
  width: 67%;
}
input[name="question_100"]{
  width: 10%;
}
input[name="question_101"]{
  width: 55.5%;
}
input[name="question_102"]{
  width: 54.5%;
}
input[name="question_103"]{
  width: 68%;
}
input[name="question_104"]{
  width: 67%;
}
input[name="question_105"]{
  width: 8%;
}
input[name="question_106"]{
  width: 8%;
}
input[name="question_107"]{
  width: 10%;
}
input[name="question_108"]{
  width: 25.5%;
}
input[name="question_109"]{
  width: 65%;
}
input[name="question_110"]{
  width: 70%;
}
#general_information .fixed_width{
  width: 250px;
  display: inline-block;
  vertical-align: bottom;
}
#general_information input{
  vertical-align: bottom;
}
.inline_right{
  display: inline-block;
  vertical-align: bottom;
}
input[name="question_111"]{
  width: 98%;
}
input[name="question_113"]{
  width: 42.5%;
}
input[name="question_116"]{
  width: 49.5%;
}
input[name="question_121"]{
  width: 74%;
}
input[name="question_122"]{
  width: 10%;
}
input[name="question_123"]{
  width: 23%;
}
input[name="question_124"]{
  width: 24%;
}
input[name="question_129"]{
  width: 98%;
}
input[name="question_130"]{
  width: 98%;
}
.col_33{
  width: 30%;
  margin: 0 1%;
  float: left;
}
#medical_problems_textbox{
  width: 98%;
  height: 75px;
}
input[name="question_166"]{
  width: 43%;
}
input[name="question_167"]{
  width: 8%;
}
input[name="question_168"]{
  width: 24%;
}
input[name="question_169"]{
  width: 87.5%;
}
input[name="question_173"],input[name="question_174"],input[name="question_175"]{
  width: 72%;
}
input[name="question_181"],input[name="question_182"],input[name="question_183"]{
  width: 25%;
}
.signature{
  float: left;
}
.signature_date{
  float: right;
  margin: 0 75px 0 0;
}
.bottom_grey{
  background-color: #333;
  padding: 5px;
  margin: 5px -5px -5px;
  color: #fff;
  text-align: center;
}
.top_grey{
  width: 100%;
  background-color: #333;
  padding: 5px;
  font-size: 20px;
  text-align: center;
  color: #fff;
  border-radius: 10px 10px 0 0;
  box-sizing: border-box;
}
.bottom_box{
  padding: 5px;
  background: #fff;
}
.bottom_interior_box{
  padding: 5px;
  background: rgb(161, 189, 210);
}
input[name="question_178"],input[name="question_179"],input[name="question_180"]{
  width: 98%;
}
@media print {
  @page {
    size: letter portrait;
    margin: 0.5cm;
  }
  #page_break {
    width: 100%;
    margin: 0 0 200px;
    clear: both;
    height: 1px;
  }
}