{"id":150,"date":"2021-02-17T16:32:04","date_gmt":"2021-02-17T21:32:04","guid":{"rendered":"http:\/\/register.advocatero.com\/?page_id=150"},"modified":"2026-01-13T15:14:41","modified_gmt":"2026-01-13T20:14:41","slug":"new-patient-registration-form-spanish","status":"publish","type":"page","link":"https:\/\/register.advocatero.com\/es\/new-patient-registration-form-spanish\/","title":{"rendered":"Formulario de registro de nuevos pacientes Espa\u00f1ol"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/es\/wp-json\/wp\/v2\/pages\/150#gf_4' data-formid='4' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/150#gf_4\"><input id=\"partial_entry_id_4\" class=\"partial_entry_id\" type=\"hidden\" name=\"partial_entry_id\" value=\"pending\" data-form_id=\"4\"\/>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>11<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_386\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_386'>Tel\u00e9fono<\/label><div class='ginput_container'><input name='input_386' id='input_4_386' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_386'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_4_326\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Formulario De Registro Del Paciente<\/h3><\/li><li id=\"field_4_311\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"color:#b72a2a;\"><b>*El asterisco indica un campo obligatorio.<\/b><\/span><\/li><li id=\"field_4_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >NOMBRE DEL PACIENTE (APELLIDO -- PRIMER NOMBRE -- INICIAL SEGUNDO NOMBRE)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub'>Primer Nombre<\/label>\n                                                <\/span>\n                            <span id='input_4_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_4_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_1_4' class='gform-field-label gform-field-label--type-sub'>Inicial Segundo Nombre<\/label>\n                                                <\/span>\n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub'>Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_2\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_2'>Correo Electr\u00f3nico<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_4_2' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_27\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>Tel\u00e9fono De Casa<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_4_27' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_5\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_5'>Tel\u00e9fono M\u00f3vil<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_4_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_7\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tel\u00e9fono M\u00f3vil - Es un iPhone?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_7'>\n\t\t\t<li class='gchoice gchoice_4_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='No'  id='choice_4_7_0'    \/>\n\t\t\t\t<label for='choice_4_7_0' id='label_4_7_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='Si'  id='choice_4_7_1'    \/>\n\t\t\t\t<label for='choice_4_7_1' id='label_4_7_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_4\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcccion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_4_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_4_1' id='input_4_4_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_4_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_4_3' id='input_4_4_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_4_4_container' >\n                                        <select name='input_4.4' id='input_4_4_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_4_4' id='input_4_4_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_4_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_4_5' id='input_4_4_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_4_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_312\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Fecha De Nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_312' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_4_312_1_container'>\n                                            <input type='number' maxlength='2' name='input_312[]' id='input_4_312_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_4_312_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_4_312_2_container'>\n                                            <input type='number' maxlength='2' name='input_312[]' id='input_4_312_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_4_312_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_4_312_3_container'>\n                                            <input type='number' maxlength='4' name='input_312[]' id='input_4_312_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_4_312_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_4_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_8'>Numero De Seguro Social<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sexo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_9'>\n\t\t\t<li class='gchoice gchoice_4_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Masculino'  id='choice_4_9_0'    \/>\n\t\t\t\t<label for='choice_4_9_0' id='label_4_9_0' class='gform-field-label gform-field-label--type-inline'>Masculino<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Femenino'  id='choice_4_9_1'    \/>\n\t\t\t\t<label for='choice_4_9_1' id='label_4_9_1' class='gform-field-label gform-field-label--type-inline'>Femenino<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Estado Civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_10'>\n\t\t\t<li class='gchoice gchoice_4_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Soltero'  id='choice_4_10_0'    \/>\n\t\t\t\t<label for='choice_4_10_0' id='label_4_10_0' class='gform-field-label gform-field-label--type-inline'>Soltero<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Casado'  id='choice_4_10_1'    \/>\n\t\t\t\t<label for='choice_4_10_1' id='label_4_10_1' class='gform-field-label gform-field-label--type-inline'>Casado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='gf_other_choice'  id='choice_4_10_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_4_10_other' name='input_10_other' type='text' value='Other' aria-label='Otros' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Nombre Del Empleador Del Paciente<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_4_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n Del Empleador Del Paciente<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_4_15_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_15_1' id='input_4_15_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_4_15_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_15_3' id='input_4_15_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_15_4_container' >\n                                        <select name='input_15.4' id='input_4_15_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_15_4' id='input_4_15_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_4_15_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_15_5' id='input_4_15_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_4_15_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_16\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Tel\u00e9fono Del Empleador<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_4_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_64\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Informacion Del Asegurado O Responsable<\/h3><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Informacion Del Asegurado O Responsable Nombre<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_4_18'>\n                            \n                            <span id='input_4_18_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.3' id='input_4_18_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_18_3' class='gform-field-label gform-field-label--type-sub'>Primer Nombre<\/label>\n                                                <\/span>\n                            <span id='input_4_18_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.4' id='input_4_18_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_18_4' class='gform-field-label gform-field-label--type-sub'>Inicial Segundo Nombre<\/label>\n                                                <\/span>\n                            <span id='input_4_18_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.6' id='input_4_18_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_18_6' class='gform-field-label gform-field-label--type-sub'>Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_314\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_314'>Relacion Con El Paciente<\/label><div class='ginput_container ginput_container_select'><select name='input_314' id='input_4_314' class='medium gfield_select'     aria-invalid=\"false\" ><option value='C\u00f3nyuge' >C\u00f3nyuge<\/option><option value='Padre' >Padre<\/option><option value='Guardi\u00e1n' >Guardi\u00e1n<\/option><option value='Yo' >Yo<\/option><\/select><\/div><\/li><li id=\"field_4_25\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n (si es diferente del paciente)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_25' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_25_1_container' >\n                                        <input type='text' name='input_25.1' id='input_4_25_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_25_1' id='input_4_25_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_25_3_container' >\n                                    <input type='text' name='input_25.3' id='input_4_25_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_25_3' id='input_4_25_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_25_4_container' >\n                                        <select name='input_25.4' id='input_4_25_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_25_4' id='input_4_25_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_25_5_container' >\n                                    <input type='text' name='input_25.5' id='input_4_25_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_25_5' id='input_4_25_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_25.6' id='input_4_25_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Informacion Del Asegurado O Responsable Tel\u00e9fono De Casa<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_28\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Informacion Del Asegurado O Responsable Tel\u00e9fono Del Trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_4_28' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Informacion Del Asegurado O Responsable Seguro Social<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_20'>Informacion Del Asegurado O Responsable Fecha Nacimiento<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Informacion Del Asegurado O Responsable Empleador<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_24\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Informacion Del Seguro Medico<\/h3><\/li><li id=\"field_4_26\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_26'>Nombre Del Seguro Primario<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_4_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_32\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direccion (al respaldo de la tarjeta del seguro m\u00e9dico)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_32_1_container' >\n                                        <input type='text' name='input_32.1' id='input_4_32_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_32_1' id='input_4_32_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_4_32_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_32_3' id='input_4_32_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_32_4_container' >\n                                        <select name='input_32.4' id='input_4_32_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_32_4' id='input_4_32_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_32_5_container' >\n                                    <input type='text' name='input_32.5' id='input_4_32_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_32_5' id='input_4_32_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_4_32_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_41\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_41'>Numero De Grupo<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_4_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_42\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_42'>Numero De Identificaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_4_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_43\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tipo de Seguro Primario<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_43'>\n\t\t\t<li class='gchoice gchoice_4_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='HMO'  id='choice_4_43_0'    \/>\n\t\t\t\t<label for='choice_4_43_0' id='label_4_43_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='PPO'  id='choice_4_43_1'    \/>\n\t\t\t\t<label for='choice_4_43_1' id='label_4_43_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_44\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_44'>Telefono Compania De Seguro<\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_4_44' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_38\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/li><li id=\"field_4_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_31'>Nombre Del Seguro Secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_4_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_19\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direccion (al respaldo de la tarjeta del seguro m\u00e9dico secundario)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_4_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_19_1' id='input_4_19_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_4_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_19_3' id='input_4_19_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_19_4_container' >\n                                        <select name='input_19.4' id='input_4_19_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_19_4' id='input_4_19_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_4_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_19_5' id='input_4_19_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_4_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_34\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_34'>Numero De Grupo Secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_4_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_35\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>Numero De Identificacion Secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_4_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_36\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tipo de Seguro Secundario<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_36'>\n\t\t\t<li class='gchoice gchoice_4_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='HMO'  id='choice_4_36_0'    \/>\n\t\t\t\t<label for='choice_4_36_0' id='label_4_36_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='PPO'  id='choice_4_36_1'    \/>\n\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_37\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_37'>Telefono Compania De Seguro Secundario<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_4_37' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_30\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Informaci\u00f3n De Admisi\u00f3n<\/h3><\/li><li id=\"field_4_45\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>Medico De Atencion Primaria<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_4_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>Nombre Del Medico Que Lo Remitio<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_47\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contacto En Caso De Emergencia<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_47'>\n                            \n                            <span id='input_4_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_4_47_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_47_3' class='gform-field-label gform-field-label--type-sub'>Primer Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_47_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.6' id='input_4_47_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_47_6' class='gform-field-label gform-field-label--type-sub'>Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_48'>Contacto En Caso De Emergencia Relacion<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_4_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_49\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_49'>Contacto En Caso De Emergencia Numero Telefonico<\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_4_49' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_52\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Actualmente se encuentra hospitalizado o est\u00e1 inscrito en un hospicio o centro de enfermer\u00eda especializada?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_52'>\n\t\t\t<li class='gchoice gchoice_4_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_4_52_0'    \/>\n\t\t\t\t<label for='choice_4_52_0' id='label_4_52_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_4_52_1'    \/>\n\t\t\t\t<label for='choice_4_52_1' id='label_4_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>Nombre de la Instituci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_4_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_57\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_57'>Instituci\u00f3n Tel\u00e9fono<\/label><div class='ginput_container ginput_container_phone'><input name='input_57' id='input_4_57' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_58\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Instituci\u00f3n Direcci\u00f3n<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_58' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_58_1_container' >\n                                        <input type='text' name='input_58.1' id='input_4_58_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_58_1' id='input_4_58_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_58_3_container' >\n                                    <input type='text' name='input_58.3' id='input_4_58_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_58_3' id='input_4_58_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_58_4_container' >\n                                        <select name='input_58.4' id='input_4_58_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_58_4' id='input_4_58_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_58_5_container' >\n                                    <input type='text' name='input_58.5' id='input_4_58_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_58_5' id='input_4_58_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_58.6' id='input_4_58_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_59\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/li><li id=\"field_4_55\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Recibe beneficios de la Administraci\u00f3n de Veteranos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_55'>\n\t\t\t<li class='gchoice gchoice_4_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Si'  id='choice_4_55_0'    \/>\n\t\t\t\t<label for='choice_4_55_0' id='label_4_55_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_4_55_1'    \/>\n\t\t\t\t<label for='choice_4_55_1' id='label_4_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Nombre de la Entidad de Administraci\u00f3n de Veteranos<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_4_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_54\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Administraci\u00f3n de Veteranos Tel\u00e9fono<\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_4_54' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_51\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Administraci\u00f3n de Veteranos Direcci\u00f3n<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_51' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_51_1_container' >\n                                        <input type='text' name='input_51.1' id='input_4_51_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_51_1' id='input_4_51_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_51_3_container' >\n                                    <input type='text' name='input_51.3' id='input_4_51_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_51_3' id='input_4_51_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_51_4_container' >\n                                        <select name='input_51.4' id='input_4_51_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_51_4' id='input_4_51_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_51_5_container' >\n                                    <input type='text' name='input_51.5' id='input_4_51_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_51_5' id='input_4_51_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_51.6' id='input_4_51_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_40\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/li><li id=\"field_4_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Cu\u00e1l de las siguientes opciones describe su raza?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_60'>\n\t\t\t<li class='gchoice gchoice_4_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Asi\u00e1tico'  id='choice_4_60_0'    \/>\n\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0' class='gform-field-label gform-field-label--type-inline'>Asi\u00e1tico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Blanco'  id='choice_4_60_1'    \/>\n\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>Blanco<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_2'>\n\t\t\t\t<input name='input_60' type='radio' value='Negro \/ Afroamericano'  id='choice_4_60_2'    \/>\n\t\t\t\t<label for='choice_4_60_2' id='label_4_60_2' class='gform-field-label gform-field-label--type-inline'>Negro \/ Afroamericano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_3'>\n\t\t\t\t<input name='input_60' type='radio' value='Hispano'  id='choice_4_60_3'    \/>\n\t\t\t\t<label for='choice_4_60_3' id='label_4_60_3' class='gform-field-label gform-field-label--type-inline'>Hispano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_4'>\n\t\t\t\t<input name='input_60' type='radio' value='Subcontinente Asi\u00e1tico Americano'  id='choice_4_60_4'    \/>\n\t\t\t\t<label for='choice_4_60_4' id='label_4_60_4' class='gform-field-label gform-field-label--type-inline'>Subcontinente Asi\u00e1tico Americano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_5'>\n\t\t\t\t<input name='input_60' type='radio' value='Asi\u00e1tico Pacifico Americano'  id='choice_4_60_5'    \/>\n\t\t\t\t<label for='choice_4_60_5' id='label_4_60_5' class='gform-field-label gform-field-label--type-inline'>Asi\u00e1tico Pacifico Americano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_6'>\n\t\t\t\t<input name='input_60' type='radio' value='Nativo Americano'  id='choice_4_60_6'    \/>\n\t\t\t\t<label for='choice_4_60_6' id='label_4_60_6' class='gform-field-label gform-field-label--type-inline'>Nativo Americano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_7'>\n\t\t\t\t<input name='input_60' type='radio' value='Indio Americano \/ Nativo de Alaska'  id='choice_4_60_7'    \/>\n\t\t\t\t<label for='choice_4_60_7' id='label_4_60_7' class='gform-field-label gform-field-label--type-inline'>Indio Americano \/ Nativo de Alaska<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_8'>\n\t\t\t\t<input name='input_60' type='radio' value='Hawaiano'  id='choice_4_60_8'    \/>\n\t\t\t\t<label for='choice_4_60_8' id='label_4_60_8' class='gform-field-label gform-field-label--type-inline'>Hawaiano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_9'>\n\t\t\t\t<input name='input_60' type='radio' value='Isle\u00f1o del Pac\u00edfico'  id='choice_4_60_9'    \/>\n\t\t\t\t<label for='choice_4_60_9' id='label_4_60_9' class='gform-field-label gform-field-label--type-inline'>Isle\u00f1o del Pac\u00edfico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_10'>\n\t\t\t\t<input name='input_60' type='radio' value='Mas de una Raza'  id='choice_4_60_10'    \/>\n\t\t\t\t<label for='choice_4_60_10' id='label_4_60_10' class='gform-field-label gform-field-label--type-inline'>Mas de una Raza<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_11'>\n\t\t\t\t<input name='input_60' type='radio' value='Otro'  id='choice_4_60_11'    \/>\n\t\t\t\t<label for='choice_4_60_11' id='label_4_60_11' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_60_12'>\n\t\t\t\t<input name='input_60' type='radio' value='Declino a Informar'  id='choice_4_60_12'    \/>\n\t\t\t\t<label for='choice_4_60_12' id='label_4_60_12' class='gform-field-label gform-field-label--type-inline'>Declino a Informar<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_61\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Favor indique un grupo \u00e9tnico que mejor describa su raza:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_61'>\n\t\t\t<li class='gchoice gchoice_4_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Hispano o Latino'  id='choice_4_61_0'    \/>\n\t\t\t\t<label for='choice_4_61_0' id='label_4_61_0' class='gform-field-label gform-field-label--type-inline'>Hispano o Latino<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='No-Hispano o Latino'  id='choice_4_61_1'    \/>\n\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>No-Hispano o Latino<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_61_2'>\n\t\t\t\t<input name='input_61' type='radio' value='Declino a Informar'  id='choice_4_61_2'    \/>\n\t\t\t\t<label for='choice_4_61_2' id='label_4_61_2' class='gform-field-label gform-field-label--type-inline'>Declino a Informar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_61_3'>\n\t\t\t\t<input name='input_61' type='radio' value='No s\u00e9'  id='choice_4_61_3'    \/>\n\t\t\t\t<label for='choice_4_61_3' id='label_4_61_3' class='gform-field-label gform-field-label--type-inline'>No s\u00e9<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_62\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >En qu\u00e9 idioma se siente m\u00e1s c\u00f3modo al hablar sobre su atenci\u00f3n m\u00e9dica?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_62'>\n\t\t\t<li class='gchoice gchoice_4_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Ingl\u00e9s'  id='choice_4_62_0'    \/>\n\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0' class='gform-field-label gform-field-label--type-inline'>Ingl\u00e9s<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Espa\u00f1ol'  id='choice_4_62_1'    \/>\n\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>Espa\u00f1ol<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_2'>\n\t\t\t\t<input name='input_62' type='radio' value='Alem\u00e1n'  id='choice_4_62_2'    \/>\n\t\t\t\t<label for='choice_4_62_2' id='label_4_62_2' class='gform-field-label gform-field-label--type-inline'>Alem\u00e1n<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_3'>\n\t\t\t\t<input name='input_62' type='radio' value='Franc\u00e9s'  id='choice_4_62_3'    \/>\n\t\t\t\t<label for='choice_4_62_3' id='label_4_62_3' class='gform-field-label gform-field-label--type-inline'>Franc\u00e9s<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_4'>\n\t\t\t\t<input name='input_62' type='radio' value='Italiano'  id='choice_4_62_4'    \/>\n\t\t\t\t<label for='choice_4_62_4' id='label_4_62_4' class='gform-field-label gform-field-label--type-inline'>Italiano<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_5'>\n\t\t\t\t<input name='input_62' type='radio' value='Ruso'  id='choice_4_62_5'    \/>\n\t\t\t\t<label for='choice_4_62_5' id='label_4_62_5' class='gform-field-label gform-field-label--type-inline'>Ruso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_6'>\n\t\t\t\t<input name='input_62' type='radio' value='Portugu\u00e9s'  id='choice_4_62_6'    \/>\n\t\t\t\t<label for='choice_4_62_6' id='label_4_62_6' class='gform-field-label gform-field-label--type-inline'>Portugu\u00e9s<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_7'>\n\t\t\t\t<input name='input_62' type='radio' value='Chino'  id='choice_4_62_7'    \/>\n\t\t\t\t<label for='choice_4_62_7' id='label_4_62_7' class='gform-field-label gform-field-label--type-inline'>Chino<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_8'>\n\t\t\t\t<input name='input_62' type='radio' value='Otro'  id='choice_4_62_8'    \/>\n\t\t\t\t<label for='choice_4_62_8' id='label_4_62_8' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_9'>\n\t\t\t\t<input name='input_62' type='radio' value='Declino a informar'  id='choice_4_62_9'    \/>\n\t\t\t\t<label for='choice_4_62_9' id='label_4_62_9' class='gform-field-label gform-field-label--type-inline'>Declino a informar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_62_10'>\n\t\t\t\t<input name='input_62' type='radio' value='No s\u00e9'  id='choice_4_62_10'    \/>\n\t\t\t\t<label for='choice_4_62_10' id='label_4_62_10' class='gform-field-label gform-field-label--type-inline'>No s\u00e9<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_63\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Con qu\u00e9 frecuencia usa internet para recopilar informaci\u00f3n?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_63'>\n\t\t\t<li class='gchoice gchoice_4_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Siempre'  id='choice_4_63_0'    \/>\n\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0' class='gform-field-label gform-field-label--type-inline'>Siempre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Generalmente'  id='choice_4_63_1'    \/>\n\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>Generalmente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_63_2'>\n\t\t\t\t<input name='input_63' type='radio' value='Algunas Veces'  id='choice_4_63_2'    \/>\n\t\t\t\t<label for='choice_4_63_2' id='label_4_63_2' class='gform-field-label gform-field-label--type-inline'>Algunas Veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_63_3'>\n\t\t\t\t<input name='input_63' type='radio' value='Nunca'  id='choice_4_63_3'    \/>\n\t\t\t\t<label for='choice_4_63_3' id='label_4_63_3' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_88' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-88' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_89\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Formularios de Historia M\u00e9dica<\/h3><\/li><li id=\"field_4_66\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_66'>Diagn\u00f3stico de c\u00e1ncer o motivo de consulta:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_4_66' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_67\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px;\">Historial M\u00e9dico<\/h3><\/li><li id=\"field_4_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Marque todo lo que corresponda:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_68'><li class='gchoice gchoice_4_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Alergias'  id='choice_4_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_1' id='label_4_68_1' class='gform-field-label gform-field-label--type-inline'>Alergias<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='Enfermedad pulmonar obstructiva cr\u00f3nica (EPOC)'  id='choice_4_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_2' id='label_4_68_2' class='gform-field-label gform-field-label--type-inline'>Enfermedad pulmonar obstructiva cr\u00f3nica (EPOC)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.3' type='checkbox'  value='Alta presi\u00f3n \/ Hipertensi\u00f3n'  id='choice_4_68_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_3' id='label_4_68_3' class='gform-field-label gform-field-label--type-inline'>Alta presi\u00f3n \/ Hipertensi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.4' type='checkbox'  value='Ansiedad'  id='choice_4_68_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_4' id='label_4_68_4' class='gform-field-label gform-field-label--type-inline'>Ansiedad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.5' type='checkbox'  value='Depresi\u00f3n'  id='choice_4_68_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_5' id='label_4_68_5' class='gform-field-label gform-field-label--type-inline'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.6' type='checkbox'  value='Enfermedad inflamatoria intestinal  (enfermedad de Crohn, colitis, etc.)'  id='choice_4_68_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_6' id='label_4_68_6' class='gform-field-label gform-field-label--type-inline'>Enfermedad inflamatoria intestinal  (enfermedad de Crohn, colitis, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.7' type='checkbox'  value='Anemia\/problemas sangu\u00edneos'  id='choice_4_68_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_7' id='label_4_68_7' class='gform-field-label gform-field-label--type-inline'>Anemia\/problemas sangu\u00edneos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.8' type='checkbox'  value='Diabetes'  id='choice_4_68_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_8' id='label_4_68_8' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.9' type='checkbox'  value='Migra\u00f1as \/ dolores de cabeza'  id='choice_4_68_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_9' id='label_4_68_9' class='gform-field-label gform-field-label--type-inline'>Migra\u00f1as \/ dolores de cabeza<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.11' type='checkbox'  value='Artritis'  id='choice_4_68_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_11' id='label_4_68_11' class='gform-field-label gform-field-label--type-inline'>Artritis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.12' type='checkbox'  value='Diverticulitis'  id='choice_4_68_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_12' id='label_4_68_12' class='gform-field-label gform-field-label--type-inline'>Diverticulitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.13' type='checkbox'  value='Neuropat\u00eda'  id='choice_4_68_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_13' id='label_4_68_13' class='gform-field-label gform-field-label--type-inline'>Neuropat\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.14' type='checkbox'  value='Asma'  id='choice_4_68_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_14' id='label_4_68_14' class='gform-field-label gform-field-label--type-inline'>Asma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.15' type='checkbox'  value='Disfunci\u00f3n er\u00e9ctil'  id='choice_4_68_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_15' id='label_4_68_15' class='gform-field-label gform-field-label--type-inline'>Disfunci\u00f3n er\u00e9ctil<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.16' type='checkbox'  value='Psicosis'  id='choice_4_68_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_16' id='label_4_68_16' class='gform-field-label gform-field-label--type-inline'>Psicosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.17' type='checkbox'  value='Fibrilaci\u00f3n auricular \/ latidos card\u00edacos irregulares'  id='choice_4_68_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_17' id='label_4_68_17' class='gform-field-label gform-field-label--type-inline'>Fibrilaci\u00f3n auricular \/ latidos card\u00edacos irregulares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.18' type='checkbox'  value='Fibromialgia'  id='choice_4_68_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_18' id='label_4_68_18' class='gform-field-label gform-field-label--type-inline'>Fibromialgia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.19' type='checkbox'  value='Artritis reumatoide'  id='choice_4_68_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_19' id='label_4_68_19' class='gform-field-label gform-field-label--type-inline'>Artritis reumatoide<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.21' type='checkbox'  value='Trastorno autoinmune (lupus, esclerodermia, AR, etc.)'  id='choice_4_68_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_21' id='label_4_68_21' class='gform-field-label gform-field-label--type-inline'>Trastorno autoinmune (lupus, esclerodermia, AR, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.22' type='checkbox'  value='Reflujo gastroesof\u00e1gico'  id='choice_4_68_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_22' id='label_4_68_22' class='gform-field-label gform-field-label--type-inline'>Reflujo gastroesof\u00e1gico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.23' type='checkbox'  value='Convulsiones'  id='choice_4_68_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_23' id='label_4_68_23' class='gform-field-label gform-field-label--type-inline'>Convulsiones<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.24' type='checkbox'  value='Trastorno bipolar'  id='choice_4_68_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_24' id='label_4_68_24' class='gform-field-label gform-field-label--type-inline'>Trastorno bipolar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.25' type='checkbox'  value='Gota'  id='choice_4_68_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_25' id='label_4_68_25' class='gform-field-label gform-field-label--type-inline'>Gota<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.26' type='checkbox'  value='Derrame Cerebral'  id='choice_4_68_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_26' id='label_4_68_26' class='gform-field-label gform-field-label--type-inline'>Derrame Cerebral<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.27' type='checkbox'  value='Co\u00e1gulos de sangre o embolia pulmonar'  id='choice_4_68_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_27' id='label_4_68_27' class='gform-field-label gform-field-label--type-inline'>Co\u00e1gulos de sangre o embolia pulmonar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.28' type='checkbox'  value='Ataque de Coraz\u00f3n'  id='choice_4_68_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_28' id='label_4_68_28' class='gform-field-label gform-field-label--type-inline'>Ataque de Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.29' type='checkbox'  value='Trastorno de la tiroides'  id='choice_4_68_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_29' id='label_4_68_29' class='gform-field-label gform-field-label--type-inline'>Trastorno de la tiroides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.31' type='checkbox'  value='Hiperplasia prost\u00e1tica benigna'  id='choice_4_68_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_31' id='label_4_68_31' class='gform-field-label gform-field-label--type-inline'>Hiperplasia prost\u00e1tica benigna<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.32' type='checkbox'  value='Enfermedades Cardiacas'  id='choice_4_68_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_32' id='label_4_68_32' class='gform-field-label gform-field-label--type-inline'>Enfermedades Cardiacas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.33' type='checkbox'  value='Temblores'  id='choice_4_68_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_33' id='label_4_68_33' class='gform-field-label gform-field-label--type-inline'>Temblores<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.34' type='checkbox'  value='Arteriopat\u00eda coronaria (CAD)'  id='choice_4_68_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_34' id='label_4_68_34' class='gform-field-label gform-field-label--type-inline'>Arteriopat\u00eda coronaria (CAD)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.35' type='checkbox'  value='Colesterol alto'  id='choice_4_68_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_35' id='label_4_68_35' class='gform-field-label gform-field-label--type-inline'>Colesterol alto<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_68_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.36' type='checkbox'  value='Osteoporosis'  id='choice_4_68_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_68_36' id='label_4_68_36' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_71'>C\u00e1ncer, historia previa:<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_4_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_72\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_72'>Enfermedad infecciosa (VIH, hepatitis, tuberculosis, etc.)?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_4_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_73\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_73'>Otro<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_4_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_83\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alguna vez ha recibido radioterapia?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_83'>\n\t\t\t<li class='gchoice gchoice_4_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Si'  id='choice_4_83_0'    \/>\n\t\t\t\t<label for='choice_4_83_0' id='label_4_83_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='No'  id='choice_4_83_1'    \/>\n\t\t\t\t<label for='choice_4_83_1' id='label_4_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_84\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>En caso afirmativo, cuando?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_4_84' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_84_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_84_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_84' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_77\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_77'>Nombre del M\u00e9dico \/Entidad:<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_4_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_86\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>Direcci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_4_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_366\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_366'>Qu\u00e9 \u00e1rea fue tratada?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_366' id='input_4_366' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_74\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alguna vez ha recibido quimioterapia?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_74'>\n\t\t\t<li class='gchoice gchoice_4_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Si'  id='choice_4_74_0'    \/>\n\t\t\t\t<label for='choice_4_74_0' id='label_4_74_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_4_74_1'    \/>\n\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_76\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_76'>En caso afirmativo, cuando?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_4_76' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_76_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_76' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_87\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>Nombre del M\u00e9dico \/Entidad:<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_4_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_80\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_80'>Direcci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_4_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px margin-top:20px;\">Cirug\u00edas Pasadas<\/h3><\/li><li id=\"field_4_107\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Indique la cirug\u00eda, el a\u00f1o de operaci\u00f3n, el cirujano y la ubicaci\u00f3n (si se conoce)<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_107_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_107_col_2' class='gfield_list_col_even' \/><col id='gfield_list_107_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_107_col_4' class='gfield_list_col_even' \/><col id='gfield_list_107_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Procedimiento\/Operaci\u00f3n<\/th><th scope=\"col\">Fecha<\/th><th scope=\"col\">M\u00e9dico<\/th><th scope=\"col\">Lugar<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_107_cell1' data-label='Procedimiento\/Operaci\u00f3n'><input aria-invalid='false'   aria-label='Procedimiento\/Operaci\u00f3n, Row 1' data-aria-label-template='Procedimiento\/Operaci\u00f3n, Row {0}' type='text' name='input_107[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_107_cell2' data-label='Fecha'><input aria-invalid='false'   aria-label='Fecha, Row 1' data-aria-label-template='Fecha, Row {0}' type='text' name='input_107[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_107_cell3' data-label='M\u00e9dico'><input aria-invalid='false'   aria-label='M\u00e9dico, Row 1' data-aria-label-template='M\u00e9dico, Row {0}' type='text' name='input_107[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_107_cell4' data-label='Lugar'><input aria-invalid='false'   aria-label='Lugar, Row 1' data-aria-label-template='Lugar, Row {0}' type='text' name='input_107[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 4)' onkeypress='gformAddListItem(this, 4)'><img src='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 4)' onkeypress='gformDeleteListItem(this, 4)' style=\"visibility:hidden;\"><img src='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_4_96\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene alg\u00fan dispositivo m\u00e9dico implantado, como un PACEMAKER, un DESFIBRILADOR, un neuro estimulador, bombas de infusi\u00f3n de drogas, etc.?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_96'>\n\t\t\t<li class='gchoice gchoice_4_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Si'  id='choice_4_96_0'    \/>\n\t\t\t\t<label for='choice_4_96_0' id='label_4_96_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='No'  id='choice_4_96_1'    \/>\n\t\t\t\t<label for='choice_4_96_1' id='label_4_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_97\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong><em>En caso afirmativo, proporcione una copia de su tarjeta de dispositivo m\u00e9dico en la recepci\u00f3n.<\/strong><\/em><\/p><\/li><li id=\"field_4_98\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Alergias<\/h3><\/li><li id=\"field_4_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Es al\u00e9rgico a alg\u00fan medicamento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_99'>\n\t\t\t<li class='gchoice gchoice_4_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Si'  id='choice_4_99_0'    \/>\n\t\t\t\t<label for='choice_4_99_0' id='label_4_99_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_4_99_1'    \/>\n\t\t\t\t<label for='choice_4_99_1' id='label_4_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_100\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_100'>En caso afirmativo, nombre \/ reacci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_4_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Es al\u00e9rgico al l\u00e1tex?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_104'>\n\t\t\t<li class='gchoice gchoice_4_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='Si'  id='choice_4_104_0'    \/>\n\t\t\t\t<label for='choice_4_104_0' id='label_4_104_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='No'  id='choice_4_104_1'    \/>\n\t\t\t\t<label for='choice_4_104_1' id='label_4_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_105\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_105'>Si es as\u00ed, reacci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_4_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Es al\u00e9rgico al contraste IV?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_103'>\n\t\t\t<li class='gchoice gchoice_4_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='Si'  id='choice_4_103_0'    \/>\n\t\t\t\t<label for='choice_4_103_0' id='label_4_103_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='No'  id='choice_4_103_1'    \/>\n\t\t\t\t<label for='choice_4_103_1' id='label_4_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_102\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_102'>Si es as\u00ed, reacci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_4_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_106\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_106'>Otros (comida, cinta, ambiental, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_4_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_108\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Medicamentos<\/h3><\/li><li id=\"field_4_109\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_109'>Nombre de la Farmacia:<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_4_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_110\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_110'>N\u00famero de la Farmacia:<\/label><div class='ginput_container ginput_container_phone'><input name='input_110' id='input_4_110' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_111\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n de la Farmacia:<\/label>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_4_111' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_111_1_container' >\n                                        <input type='text' name='input_111.1' id='input_4_111_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_111_1' id='input_4_111_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_111.4' id='input_4_111_4' value=''\/><input type='hidden' class='gform_hidden' name='input_111.6' id='input_4_111_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_90\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Enumere TODOS los medicamentos. Haga clic en el s\u00edmbolo &quot;M\u00c1S&quot; para agregar m\u00e1s filas.<\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_90_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_90_col_2' class='gfield_list_col_even' \/><col id='gfield_list_90_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_90_col_4' class='gfield_list_col_even' \/><col id='gfield_list_90_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Medicamento<\/th><th scope=\"col\">Dosis<\/th><th scope=\"col\">Frecuencia<\/th><th scope=\"col\">M\u00e9dico que prescribe<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_90_cell1' data-label='Medicamento'><input aria-invalid='false'   aria-label='Medicamento, Row 1' data-aria-label-template='Medicamento, Row {0}' type='text' name='input_90[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_90_cell2' data-label='Dosis'><input aria-invalid='false'   aria-label='Dosis, Row 1' data-aria-label-template='Dosis, Row {0}' type='text' name='input_90[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_90_cell3' data-label='Frecuencia'><input aria-invalid='false'   aria-label='Frecuencia, Row 1' data-aria-label-template='Frecuencia, Row {0}' type='text' name='input_90[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_90_cell4' data-label='M\u00e9dico que prescribe'><input aria-invalid='false'   aria-label='M\u00e9dico que prescribe, Row 1' data-aria-label-template='M\u00e9dico que prescribe, Row {0}' type='text' name='input_90[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 4)' onkeypress='gformAddListItem(this, 4)'><img src='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 4)' onkeypress='gformDeleteListItem(this, 4)' style=\"visibility:hidden;\"><img src='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_370' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_370' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_3' class='gform_page' data-js='page-field-id-370' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_128\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Consentimiento para obtener el historial de medicamentos del paciente<\/h3>\n<p>El historial de medicamentos del paciente es una lista de prescripciones que le han recetado los proveedores de\natenci\u00f3n m\u00e9dica. Una variedad de fuentes, incluidas farmacias y aseguradoras de salud, contribuyen a la\nrecopilaci\u00f3n de este historial.<\/p>\n<p>La informaci\u00f3n recopilada se almacena en el sistema de registro m\u00e9dico electr\u00f3nico de la cl\u00ednica y se convierte en parte de su registro m\u00e9dico personal. El historial de medicamentos es muy importante para ayudar a los doctores yasistentes m\u00e9dicos a tratar sus s\u00edntomas y \/ o enfermedad de manera adecuada y evitar interacciones de medicamentos potencialmente peligrosos.<\/p>\n<p>Es muy importante que usted y su doctor discutan todos sus edicamentos para asegurarse de que su historial de medicamento registrado sea 100% exacto. Algunas farmacias no ofrecen informaci\u00f3n sobre el historial de prescripciones, y es posible que su historial de medicamentos no incluya los medicamentos comprados sin usar su seguro m\u00e9dico.<\/p>\n<p>Adem\u00e1s, es posible que no se incluyan los medicamentos de venta libre, los suplementos o los remedios herbales que usted toma por su cuenta.<\/p><\/li><li id=\"field_4_372\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_372.1' id='input_4_372_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_372_1' >Doy mi permiso para permitir que mi doctor y asistentes m\u00e9dicos obtenga mi historial de medicamentos de mi farmacia, mis planes de salud y mis otros proveedores de atenci\u00f3n m\u00e9dica. <strong>Valido por 1 a\u00f1o desde la fecha de la firma<\/strong><\/label><input type='hidden' name='input_372.2' value='Doy mi permiso para permitir que mi doctor y asistentes m\u00e9dicos obtenga mi historial de medicamentos de mi farmacia, mis planes de salud y mis otros proveedores de atenci\u00f3n m\u00e9dica. &lt;strong&gt;Valido por 1 a\u00f1o desde la fecha de la firma&lt;\/strong&gt;' class='gform_hidden' \/><input type='hidden' name='input_372.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_373\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_373'>Nombre del Paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_373' id='input_4_373' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_374\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_374'>Fecha:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_374' id='input_4_374' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_374_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_374_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_374' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_121' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_121' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_4' class='gform_page' data-js='page-field-id-121' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_371\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Historia Familiar<\/h3><\/li><li id=\"field_4_118\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_118'>Padre: si vive, edad<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_4_118' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_119\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_119'>si falleci\u00f3, edad de fallecimiento:<\/label><div class='ginput_container ginput_container_number'><input name='input_119' id='input_4_119' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_120\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_120'>Problemas M\u00e9dicos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_4_120' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_122\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_122'>Madre: si vive, edad<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_4_122' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_116\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_116'>si falleci\u00f3, edad de fallecimiento:<\/label><div class='ginput_container ginput_container_number'><input name='input_116' id='input_4_116' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_124\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_124'>Problemas M\u00e9dicos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_4_124' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_125\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_125'>Hermanos: # de hermanas<\/label><div class='ginput_container ginput_container_number'><input name='input_125' id='input_4_125' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_369\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_369'># de hermanos<\/label><div class='ginput_container ginput_container_number'><input name='input_369' id='input_4_369' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_127\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_127'>Hijos: # de Hijas<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_4_127' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_115\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_115'># de Hijos<\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_4_115' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_117\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_117'>Problemas M\u00e9dicos\/Fallecidos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_117' id='input_4_117' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_165\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"margin-bottom:20px;\">Historial Social<\/h3><\/li><li id=\"field_4_129\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Estado Civil:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_129'>\n\t\t\t<li class='gchoice gchoice_4_129_0'>\n\t\t\t\t<input name='input_129' type='radio' value='Soltero'  id='choice_4_129_0'    \/>\n\t\t\t\t<label for='choice_4_129_0' id='label_4_129_0' class='gform-field-label gform-field-label--type-inline'>Soltero<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_129_1'>\n\t\t\t\t<input name='input_129' type='radio' value='Casado'  id='choice_4_129_1'    \/>\n\t\t\t\t<label for='choice_4_129_1' id='label_4_129_1' class='gform-field-label gform-field-label--type-inline'>Casado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_129_2'>\n\t\t\t\t<input name='input_129' type='radio' value='Divorciado'  id='choice_4_129_2'    \/>\n\t\t\t\t<label for='choice_4_129_2' id='label_4_129_2' class='gform-field-label gform-field-label--type-inline'>Divorciado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_129_3'>\n\t\t\t\t<input name='input_129' type='radio' value='Viudo'  id='choice_4_129_3'    \/>\n\t\t\t\t<label for='choice_4_129_3' id='label_4_129_3' class='gform-field-label gform-field-label--type-inline'>Viudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_129_4'>\n\t\t\t\t<input name='input_129' type='radio' value='Separado'  id='choice_4_129_4'    \/>\n\t\t\t\t<label for='choice_4_129_4' id='label_4_129_4' class='gform-field-label gform-field-label--type-inline'>Separado<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_130\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_130'>Nombre del c\u00f3nyuge u otra persona significativa:<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_4_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_137\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Historia Socio-Geogr\u00e1fica:<\/h3><\/li><li id=\"field_4_132\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_132'>Donde naci\u00f3?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_4_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_133\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_133'>Donde ha vivido la mayor parte de su vida?<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_4_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_136\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Vive en este estado todo el a\u00f1o??<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_136'>\n\t\t\t<li class='gchoice gchoice_4_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='Si'  id='choice_4_136_0'    \/>\n\t\t\t\t<label for='choice_4_136_0' id='label_4_136_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='No'  id='choice_4_136_1'    \/>\n\t\t\t\t<label for='choice_4_136_1' id='label_4_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_135\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Si no, proporcione su direcci\u00f3n alternativa:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_135' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_135_1_container' >\n                                        <input type='text' name='input_135.1' id='input_4_135_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_135_1' id='input_4_135_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_135_3_container' >\n                                    <input type='text' name='input_135.3' id='input_4_135_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_135_3' id='input_4_135_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_135_4_container' >\n                                        <select name='input_135.4' id='input_4_135_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_4_135_4' id='input_4_135_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_135_5_container' >\n                                    <input type='text' name='input_135.5' id='input_4_135_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_135_5' id='input_4_135_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_135.6' id='input_4_135_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_131\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Ocupaci\u00f3n \/ Historial de Servicio<\/h3><\/li><li id=\"field_4_138\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_138'>Ocupaci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_4_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_141\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ha estado en el ejercito?Estas jubilado o discapacitado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_141'>\n\t\t\t<li class='gchoice gchoice_4_141_0'>\n\t\t\t\t<input name='input_141' type='radio' value='Retired'  id='choice_4_141_0'    \/>\n\t\t\t\t<label for='choice_4_141_0' id='label_4_141_0' class='gform-field-label gform-field-label--type-inline'>Retirado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_141_1'>\n\t\t\t\t<input name='input_141' type='radio' value='Disabled'  id='choice_4_141_1'    \/>\n\t\t\t\t<label for='choice_4_141_1' id='label_4_141_1' class='gform-field-label gform-field-label--type-inline'>Discapacitados<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_139\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_139'>Discapacitado, raz\u00f3n?<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_4_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_140\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ha estado en el ejercito?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_140'>\n\t\t\t<li class='gchoice gchoice_4_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_4_140_0'    \/>\n\t\t\t\t<label for='choice_4_140_0' id='label_4_140_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='Si'  id='choice_4_140_1'    \/>\n\t\t\t\t<label for='choice_4_140_1' id='label_4_140_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_145\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Que usted sepa, \u00bfalguna vez trabaj\u00f3 en una ocupaci\u00f3n que implicara la exposici\u00f3n al asbesto u otras sustancias qu\u00edmicas cancerosas, humos o carcin\u00f3genos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_145'>\n\t\t\t<li class='gchoice gchoice_4_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='No'  id='choice_4_145_0'    \/>\n\t\t\t\t<label for='choice_4_145_0' id='label_4_145_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='Si'  id='choice_4_145_1'    \/>\n\t\t\t\t<label for='choice_4_145_1' id='label_4_145_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_143\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_143'>En caso afirmativo, describa:<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_4_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_144\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Historial de Sustancias<\/h3><\/li><li id=\"field_4_154\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alguna vez ha fumado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_154'>\n\t\t\t<li class='gchoice gchoice_4_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='No'  id='choice_4_154_0'    \/>\n\t\t\t\t<label for='choice_4_154_0' id='label_4_154_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='Si'  id='choice_4_154_1'    \/>\n\t\t\t\t<label for='choice_4_154_1' id='label_4_154_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_150\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Si s\u00ed, que?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_150'><li class='gchoice gchoice_4_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='Cigarrillos'  id='choice_4_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_150_1' id='label_4_150_1' class='gform-field-label gform-field-label--type-inline'>Cigarrillos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='Cigarros'  id='choice_4_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_150_2' id='label_4_150_2' class='gform-field-label gform-field-label--type-inline'>Cigarros<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_150_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.3' type='checkbox'  value='Pipa'  id='choice_4_150_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_150_3' id='label_4_150_3' class='gform-field-label gform-field-label--type-inline'>Pipa<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_153\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_153'>Por cu\u00e1ntos a\u00f1os?<\/label><div class='ginput_container ginput_container_number'><input name='input_153' id='input_4_153' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_4_153\" \/><div class='gfield_description instruction' id='gfield_instruction_4_153'>Please enter a number from <strong>1<\/strong> to <strong>99<\/strong>.<\/div><\/div><\/li><li id=\"field_4_155\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_155'>Paquetes\/n\u00fameros por d\u00eda?<\/label><div class='ginput_container ginput_container_number'><input name='input_155' id='input_4_155' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_4_155\" \/><div class='gfield_description instruction' id='gfield_instruction_4_155'>Please enter a number from <strong>1<\/strong> to <strong>99<\/strong>.<\/div><\/div><\/li><li id=\"field_4_142\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Si es as\u00ed, lo ha dejado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_142'>\n\t\t\t<li class='gchoice gchoice_4_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_4_142_0'    \/>\n\t\t\t\t<label for='choice_4_142_0' id='label_4_142_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='Si'  id='choice_4_142_1'    \/>\n\t\t\t\t<label for='choice_4_142_1' id='label_4_142_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_159\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_159'>Si s\u00ed, cu\u00e1ndo?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_159' id='input_4_159' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_159_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_159_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_159' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_146\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alguna vez ha masticado tabaco?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_146'>\n\t\t\t<li class='gchoice gchoice_4_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='No'  id='choice_4_146_0'    \/>\n\t\t\t\t<label for='choice_4_146_0' id='label_4_146_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='Si'  id='choice_4_146_1'    \/>\n\t\t\t\t<label for='choice_4_146_1' id='label_4_146_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_160\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_160'>Cuanto?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_4_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_161\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Si es as\u00ed, lo ha dejado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_161'>\n\t\t\t<li class='gchoice gchoice_4_161_0'>\n\t\t\t\t<input name='input_161' type='radio' value='No'  id='choice_4_161_0'    \/>\n\t\t\t\t<label for='choice_4_161_0' id='label_4_161_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_161_1'>\n\t\t\t\t<input name='input_161' type='radio' value='Si'  id='choice_4_161_1'    \/>\n\t\t\t\t<label for='choice_4_161_1' id='label_4_161_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_162\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_162'>Si s\u00ed, cu\u00e1ndo?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_162' id='input_4_162' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_162_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_162_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_162' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_147\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Toma bebidas alcoh\u00f3licas?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_147'>\n\t\t\t<li class='gchoice gchoice_4_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='No'  id='choice_4_147_0'    \/>\n\t\t\t\t<label for='choice_4_147_0' id='label_4_147_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='Si'  id='choice_4_147_1'    \/>\n\t\t\t\t<label for='choice_4_147_1' id='label_4_147_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_157\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_157'>) En caso afirmativo, con qu\u00e9 frecuencia y cu\u00e1nto?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_4_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_158\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ha dejado de beber?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_158'>\n\t\t\t<li class='gchoice gchoice_4_158_0'>\n\t\t\t\t<input name='input_158' type='radio' value='No'  id='choice_4_158_0'    \/>\n\t\t\t\t<label for='choice_4_158_0' id='label_4_158_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_158_1'>\n\t\t\t\t<input name='input_158' type='radio' value='Si'  id='choice_4_158_1'    \/>\n\t\t\t\t<label for='choice_4_158_1' id='label_4_158_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_156\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_156'>Si s\u00ed, cu\u00e1ndo?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_156' id='input_4_156' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_156_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_156_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_156' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_148\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ha usado o usa drogas ilegales?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_148'>\n\t\t\t<li class='gchoice gchoice_4_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_4_148_0'    \/>\n\t\t\t\t<label for='choice_4_148_0' id='label_4_148_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='Si'  id='choice_4_148_1'    \/>\n\t\t\t\t<label for='choice_4_148_1' id='label_4_148_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_163\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_163'>En caso afirmativo, describa:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_163' id='input_4_163' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_50' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_5' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_178\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Mantenimiento Preventivo de Salud<\/h3><\/li><li id=\"field_4_351\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_351'>(Mujeres) \u00daltima mamograf\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_351' id='input_4_351' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_352\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_352'>(Mujeres) \u00daltima prueba de Papanicolaou:<\/label><div class='ginput_container ginput_container_text'><input name='input_352' id='input_4_352' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_353\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_353'>(Mujeres) \u00daltima colonoscopia:<\/label><div class='ginput_container ginput_container_text'><input name='input_353' id='input_4_353' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_354\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_354'>(Mujeres) \u00daltima prueba de densidad \u00f3sea:<\/label><div class='ginput_container ginput_container_text'><input name='input_354' id='input_4_354' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_355\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_355'>\u00daltima vacuna contra la neumon\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_355' id='input_4_355' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_356\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_356'>(Mujeres) \u00daltima vacuna contra la influenza:<\/label><div class='ginput_container ginput_container_text'><input name='input_356' id='input_4_356' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_357\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_357'>(Hombres) \u00daltima Prueba de PSA:<\/label><div class='ginput_container ginput_container_text'><input name='input_357' id='input_4_357' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_358\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_358'>(Hombres) \u00daltimo examen de pr\u00f3stata:<\/label><div class='ginput_container ginput_container_text'><input name='input_358' id='input_4_358' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_359\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_359'>(Hombres) \u00daltima colonoscopia:<\/label><div class='ginput_container ginput_container_text'><input name='input_359' id='input_4_359' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_360\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_360'>(Hombres) \u00daltima prueba de densidad \u00f3sea:<\/label><div class='ginput_container ginput_container_text'><input name='input_360' id='input_4_360' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_361\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_361'>(Hombres) \u00daltima vacuna contra la neumon\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_361' id='input_4_361' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_362\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_362'>(Hombres) \u00daltima vacuna contra la influenza:<\/label><div class='ginput_container ginput_container_text'><input name='input_362' id='input_4_362' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_113\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Evaluaci\u00f3n de Riesgos de Movilidad<\/h3><\/li><li id=\"field_4_182\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Necesita ayuda para caminar?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_182'>\n\t\t\t<li class='gchoice gchoice_4_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='No'  id='choice_4_182_0'    \/>\n\t\t\t\t<label for='choice_4_182_0' id='label_4_182_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='Si'  id='choice_4_182_1'    \/>\n\t\t\t\t<label for='choice_4_182_1' id='label_4_182_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_367\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Se ha ca\u00eddo antes o se ha lesionado debido a una ca\u00edda?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_367'>\n\t\t\t<li class='gchoice gchoice_4_367_0'>\n\t\t\t\t<input name='input_367' type='radio' value='No'  id='choice_4_367_0'    \/>\n\t\t\t\t<label for='choice_4_367_0' id='label_4_367_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_367_1'>\n\t\t\t\t<input name='input_367' type='radio' value='Si'  id='choice_4_367_1'    \/>\n\t\t\t\t<label for='choice_4_367_1' id='label_4_367_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_180\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >En caso afirmativo, utiliza<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_180'><li class='gchoice gchoice_4_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='bast\u00f3n?'  id='choice_4_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_180_1' id='label_4_180_1' class='gform-field-label gform-field-label--type-inline'>bast\u00f3n?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_180_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.2' type='checkbox'  value='caminador?'  id='choice_4_180_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_180_2' id='label_4_180_2' class='gform-field-label gform-field-label--type-inline'>caminador?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_180_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.3' type='checkbox'  value='silla de ruedas?'  id='choice_4_180_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_180_3' id='label_4_180_3' class='gform-field-label gform-field-label--type-inline'>silla de ruedas?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_183\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Te sientes m\u00e1s d\u00e9bil de lo que sol\u00edas o tienes menos fuerza en tus brazos o piernas?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_183'>\n\t\t\t<li class='gchoice gchoice_4_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_4_183_0'    \/>\n\t\t\t\t<label for='choice_4_183_0' id='label_4_183_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='Si'  id='choice_4_183_1'    \/>\n\t\t\t\t<label for='choice_4_183_1' id='label_4_183_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_184\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ha dejado o ha evitado hacer ejercicio \/ actividades diarias por temor a caerse?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_184'>\n\t\t\t<li class='gchoice gchoice_4_184_0'>\n\t\t\t\t<input name='input_184' type='radio' value='No'  id='choice_4_184_0'    \/>\n\t\t\t\t<label for='choice_4_184_0' id='label_4_184_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_184_1'>\n\t\t\t\t<input name='input_184' type='radio' value='Si'  id='choice_4_184_1'    \/>\n\t\t\t\t<label for='choice_4_184_1' id='label_4_184_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_185\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene \u00falceras en los pies, juanetes, deformaciones en los dedos o callosidades que le duelen al caminar?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_185'>\n\t\t\t<li class='gchoice gchoice_4_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_4_185_0'    \/>\n\t\t\t\t<label for='choice_4_185_0' id='label_4_185_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='Si'  id='choice_4_185_1'    \/>\n\t\t\t\t<label for='choice_4_185_1' id='label_4_185_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_186\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Se siente mareado cuando se levanta?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_186'>\n\t\t\t<li class='gchoice gchoice_4_186_0'>\n\t\t\t\t<input name='input_186' type='radio' value='No'  id='choice_4_186_0'    \/>\n\t\t\t\t<label for='choice_4_186_0' id='label_4_186_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_186_1'>\n\t\t\t\t<input name='input_186' type='radio' value='Si'  id='choice_4_186_1'    \/>\n\t\t\t\t<label for='choice_4_186_1' id='label_4_186_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_187\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_187'>Cu\u00e1ntas ca\u00eddas ha tenido en los \u00faltimos 12 meses?<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_4_187' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_188\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sufri\u00f3 alguna lesi\u00f3n por sus ca\u00eddas??<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_188'>\n\t\t\t<li class='gchoice gchoice_4_188_0'>\n\t\t\t\t<input name='input_188' type='radio' value='No'  id='choice_4_188_0'    \/>\n\t\t\t\t<label for='choice_4_188_0' id='label_4_188_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_188_1'>\n\t\t\t\t<input name='input_188' type='radio' value='Si'  id='choice_4_188_1'    \/>\n\t\t\t\t<label for='choice_4_188_1' id='label_4_188_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_189\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_189'>En caso afirmativo, expl\u00edquelo:<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_4_189' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_190\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Solo para Mujeres<\/h4><\/li><li id=\"field_4_191\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_191'>Edad al primer per\u00edodo menstrual:<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_4_191' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_192\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Todav\u00eda tiene per\u00edodos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_192'>\n\t\t\t<li class='gchoice gchoice_4_192_0'>\n\t\t\t\t<input name='input_192' type='radio' value='No'  id='choice_4_192_0'    \/>\n\t\t\t\t<label for='choice_4_192_0' id='label_4_192_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_192_1'>\n\t\t\t\t<input name='input_192' type='radio' value='Si'  id='choice_4_192_1'    \/>\n\t\t\t\t<label for='choice_4_192_1' id='label_4_192_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_193\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_193'>Fecha o edad del \u00faltimo per\u00edodo menstrual:<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_194\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_194'>Edad al primer embarazo:<\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_4_194' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_195\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_195'>N\u00famero de embarazos:<\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_4_195' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_197\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_197'>N\u00famero de nacimientos:<\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_4_197' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_198\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Amamanto?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_198'>\n\t\t\t<li class='gchoice gchoice_4_198_0'>\n\t\t\t\t<input name='input_198' type='radio' value='No'  id='choice_4_198_0'    \/>\n\t\t\t\t<label for='choice_4_198_0' id='label_4_198_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_198_1'>\n\t\t\t\t<input name='input_198' type='radio' value='Si'  id='choice_4_198_1'    \/>\n\t\t\t\t<label for='choice_4_198_1' id='label_4_198_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_199\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alguna vez ha tomado terapia de reemplazo hormonal?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_199'>\n\t\t\t<li class='gchoice gchoice_4_199_0'>\n\t\t\t\t<input name='input_199' type='radio' value='No'  id='choice_4_199_0'    \/>\n\t\t\t\t<label for='choice_4_199_0' id='label_4_199_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_199_1'>\n\t\t\t\t<input name='input_199' type='radio' value='Si'  id='choice_4_199_1'    \/>\n\t\t\t\t<label for='choice_4_199_1' id='label_4_199_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_200\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_200'>En caso afirmativo, cu\u00e1ntos a\u00f1os?<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_4_200' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_201\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Evaluaci\u00f3n del Dolor<\/h3><\/li><li id=\"field_4_202\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene dolor ahora?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_202'>\n\t\t\t<li class='gchoice gchoice_4_202_0'>\n\t\t\t\t<input name='input_202' type='radio' value='No'  id='choice_4_202_0'    \/>\n\t\t\t\t<label for='choice_4_202_0' id='label_4_202_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_202_1'>\n\t\t\t\t<input name='input_202' type='radio' value='Si'  id='choice_4_202_1'    \/>\n\t\t\t\t<label for='choice_4_202_1' id='label_4_202_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_203\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_203'>D\u00f3nde se encuentra su dolor?<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_4_203' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_204\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >En escala de 1a10, con 1 siendo muy leve y 10 siendo el peor dolor imaginable, qu\u00e9 n\u00famero es su dolor?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_204'><li class='gchoice gchoice_4_204_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.1' type='checkbox'  value='1'  id='choice_4_204_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_1' id='label_4_204_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.2' type='checkbox'  value='2'  id='choice_4_204_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_2' id='label_4_204_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.3' type='checkbox'  value='3'  id='choice_4_204_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_3' id='label_4_204_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.4' type='checkbox'  value='4'  id='choice_4_204_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_4' id='label_4_204_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.5' type='checkbox'  value='5'  id='choice_4_204_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_5' id='label_4_204_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.6' type='checkbox'  value='6'  id='choice_4_204_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_6' id='label_4_204_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.7' type='checkbox'  value='7'  id='choice_4_204_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_7' id='label_4_204_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.8' type='checkbox'  value='8'  id='choice_4_204_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_8' id='label_4_204_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.9' type='checkbox'  value='9'  id='choice_4_204_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_9' id='label_4_204_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_204_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.11' type='checkbox'  value='10'  id='choice_4_204_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_204_11' id='label_4_204_11' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_205\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_205'>C\u00f3mo describir\u00eda el dolor? (por ejemplo, dolor, punzante, ardor, palpitante, agudo)<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_4_205' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_206\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_206'>Cuando comenz\u00f3 su dolor?<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_4_206' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_207\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_207'>Hay algo que lo haga mejor o peor?<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_4_207' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_208\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Est\u00e1 tomando analg\u00e9sicos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_208'>\n\t\t\t<li class='gchoice gchoice_4_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='No'  id='choice_4_208_0'    \/>\n\t\t\t\t<label for='choice_4_208_0' id='label_4_208_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='Si'  id='choice_4_208_1'    \/>\n\t\t\t\t<label for='choice_4_208_1' id='label_4_208_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_209\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_209'>Si s\u00ed, que?<\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_4_209' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_210' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_210' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_6' class='gform_page' data-js='page-field-id-210' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_211\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Revisi\u00f3n de Sistemas<\/h3>\n<strong>Ha experimentado recientemente alguno de estos s\u00edntomas? Por favor seleccione todas las respuestas v\u00e1lidas<\/strong><\/li><li id=\"field_4_212\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >General<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_212'><li class='gchoice gchoice_4_212_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.1' type='checkbox'  value='Fiebre \/ escalofr\u00edos'  id='choice_4_212_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_212_1' id='label_4_212_1' class='gform-field-label gform-field-label--type-inline'>Fiebre \/ escalofr\u00edos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_212_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.2' type='checkbox'  value='Fatiga'  id='choice_4_212_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_212_2' id='label_4_212_2' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_212_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.3' type='checkbox'  value='Perdida\/ganancia de peso____  lbs.'  id='choice_4_212_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_212_3' id='label_4_212_3' class='gform-field-label gform-field-label--type-inline'>Perdida\/ganancia de peso____  lbs.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_214\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Ojos y visi\u00f3n<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_214'><li class='gchoice gchoice_4_214_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.1' type='checkbox'  value='Gafas \/ lentes de contacto'  id='choice_4_214_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_214_1' id='label_4_214_1' class='gform-field-label gform-field-label--type-inline'>Gafas \/ lentes de contacto<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_214_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.2' type='checkbox'  value='Enfermedad o lesi\u00f3n ocular'  id='choice_4_214_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_214_2' id='label_4_214_2' class='gform-field-label gform-field-label--type-inline'>Enfermedad o lesi\u00f3n ocular<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_214_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.3' type='checkbox'  value='Dolor o presi\u00f3n en los ojos'  id='choice_4_214_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_214_3' id='label_4_214_3' class='gform-field-label gform-field-label--type-inline'>Dolor o presi\u00f3n en los ojos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_214_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.4' type='checkbox'  value='Visi\u00f3n borrosa o doble'  id='choice_4_214_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_214_4' id='label_4_214_4' class='gform-field-label gform-field-label--type-inline'>Visi\u00f3n borrosa o doble<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_215\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Orejas, nariz, garganta<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_215'><li class='gchoice gchoice_4_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Perdida de la audici\u00f3n'  id='choice_4_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_1' id='label_4_215_1' class='gform-field-label gform-field-label--type-inline'>Perdida de la audici\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='Zumbidos en los o\u00eddos'  id='choice_4_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_2' id='label_4_215_2' class='gform-field-label gform-field-label--type-inline'>Zumbidos en los o\u00eddos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.3' type='checkbox'  value='Dolor de o\u00eddo o drenaje'  id='choice_4_215_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_3' id='label_4_215_3' class='gform-field-label gform-field-label--type-inline'>Dolor de o\u00eddo o drenaje<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.4' type='checkbox'  value='Problemas sinusales'  id='choice_4_215_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_4' id='label_4_215_4' class='gform-field-label gform-field-label--type-inline'>Problemas sinusales<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.5' type='checkbox'  value='Sangrado de nariz'  id='choice_4_215_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_5' id='label_4_215_5' class='gform-field-label gform-field-label--type-inline'>Sangrado de nariz<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.6' type='checkbox'  value='Problemas dentales'  id='choice_4_215_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_6' id='label_4_215_6' class='gform-field-label gform-field-label--type-inline'>Problemas dentales<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.7' type='checkbox'  value='Dentadura postiza'  id='choice_4_215_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_7' id='label_4_215_7' class='gform-field-label gform-field-label--type-inline'>Dentadura postiza<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.8' type='checkbox'  value='\u00dalceras en la boca'  id='choice_4_215_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_8' id='label_4_215_8' class='gform-field-label gform-field-label--type-inline'>\u00dalceras en la boca<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.9' type='checkbox'  value='Dolor de garganta'  id='choice_4_215_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_9' id='label_4_215_9' class='gform-field-label gform-field-label--type-inline'>Dolor de garganta<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.11' type='checkbox'  value='Dificultad \/ dolor al tragar'  id='choice_4_215_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_11' id='label_4_215_11' class='gform-field-label gform-field-label--type-inline'>Dificultad \/ dolor al tragar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.12' type='checkbox'  value='Ronquera o cambio de voz'  id='choice_4_215_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_12' id='label_4_215_12' class='gform-field-label gform-field-label--type-inline'>Ronquera o cambio de voz<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_215_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.13' type='checkbox'  value='Gl\u00e1ndulas inflamadas en el cuello'  id='choice_4_215_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_215_13' id='label_4_215_13' class='gform-field-label gform-field-label--type-inline'>Gl\u00e1ndulas inflamadas en el cuello<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_216\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Coraz\u00f3n\/Cardiovascular<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_216'><li class='gchoice gchoice_4_216_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.1' type='checkbox'  value='Dolor de Pecho'  id='choice_4_216_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_216_1' id='label_4_216_1' class='gform-field-label gform-field-label--type-inline'>Dolor de Pecho<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_216_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.2' type='checkbox'  value='Palpitaciones de Coraz\u00f3n'  id='choice_4_216_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_216_2' id='label_4_216_2' class='gform-field-label gform-field-label--type-inline'>Palpitaciones de Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_216_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.3' type='checkbox'  value='Mareo'  id='choice_4_216_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_216_3' id='label_4_216_3' class='gform-field-label gform-field-label--type-inline'>Mareo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_216_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.4' type='checkbox'  value='Piernas \/ tobillos hinchados'  id='choice_4_216_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_216_4' id='label_4_216_4' class='gform-field-label gform-field-label--type-inline'>Piernas \/ tobillos hinchados<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_217\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Respiratorio<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_217'><li class='gchoice gchoice_4_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Tos frecuente'  id='choice_4_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_217_1' id='label_4_217_1' class='gform-field-label gform-field-label--type-inline'>Tos frecuente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='Escupiendo sangre'  id='choice_4_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_217_2' id='label_4_217_2' class='gform-field-label gform-field-label--type-inline'>Escupiendo sangre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_217_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.3' type='checkbox'  value='Sibilancia o asma'  id='choice_4_217_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_217_3' id='label_4_217_3' class='gform-field-label gform-field-label--type-inline'>Sibilancia o asma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_217_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.4' type='checkbox'  value='Dificultad para respirar'  id='choice_4_217_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_217_4' id='label_4_217_4' class='gform-field-label gform-field-label--type-inline'>Dificultad para respirar<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_218\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Endocrino<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_218'><li class='gchoice gchoice_4_218_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.1' type='checkbox'  value='P\u00e9rdida\/debilitamiento de cabello'  id='choice_4_218_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_218_1' id='label_4_218_1' class='gform-field-label gform-field-label--type-inline'>P\u00e9rdida\/debilitamiento de cabello<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_218_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.2' type='checkbox'  value='Intolerancia al calor \/ fr\u00edo'  id='choice_4_218_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_218_2' id='label_4_218_2' class='gform-field-label gform-field-label--type-inline'>Intolerancia al calor \/ fr\u00edo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_218_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.3' type='checkbox'  value='Sed excesiva'  id='choice_4_218_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_218_3' id='label_4_218_3' class='gform-field-label gform-field-label--type-inline'>Sed excesiva<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_219\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Gastrointestinal<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_219'><li class='gchoice gchoice_4_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='P\u00e9rdida del apetito'  id='choice_4_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_1' id='label_4_219_1' class='gform-field-label gform-field-label--type-inline'>P\u00e9rdida del apetito<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Nausea o Vomito'  id='choice_4_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_2' id='label_4_219_2' class='gform-field-label gform-field-label--type-inline'>Nausea o Vomito<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_219_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.3' type='checkbox'  value='Dolor de est\u00f3mago'  id='choice_4_219_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_3' id='label_4_219_3' class='gform-field-label gform-field-label--type-inline'>Dolor de est\u00f3mago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_219_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.4' type='checkbox'  value='Diarrea frecuente'  id='choice_4_219_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_4' id='label_4_219_4' class='gform-field-label gform-field-label--type-inline'>Diarrea frecuente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_219_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.5' type='checkbox'  value='Constipaci\u00f3n'  id='choice_4_219_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_5' id='label_4_219_5' class='gform-field-label gform-field-label--type-inline'>Constipaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_219_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.6' type='checkbox'  value='Sangre en las heces'  id='choice_4_219_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_219_6' id='label_4_219_6' class='gform-field-label gform-field-label--type-inline'>Sangre en las heces<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_220\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Genitourinario<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_220'><li class='gchoice gchoice_4_220_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.1' type='checkbox'  value='Evacuaci\u00f3n urinaria frecuente'  id='choice_4_220_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_1' id='label_4_220_1' class='gform-field-label gform-field-label--type-inline'>Evacuaci\u00f3n urinaria frecuente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.2' type='checkbox'  value='Ardor o dolor al orinar'  id='choice_4_220_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_2' id='label_4_220_2' class='gform-field-label gform-field-label--type-inline'>Ardor o dolor al orinar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.3' type='checkbox'  value='Sangre en la orina'  id='choice_4_220_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_3' id='label_4_220_3' class='gform-field-label gform-field-label--type-inline'>Sangre en la orina<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.4' type='checkbox'  value='Incontinencia o goteo'  id='choice_4_220_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_4' id='label_4_220_4' class='gform-field-label gform-field-label--type-inline'>Incontinencia o goteo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.5' type='checkbox'  value='Urgencia'  id='choice_4_220_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_5' id='label_4_220_5' class='gform-field-label gform-field-label--type-inline'>Urgencia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.6' type='checkbox'  value='Flujo vaginal'  id='choice_4_220_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_6' id='label_4_220_6' class='gform-field-label gform-field-label--type-inline'>Flujo vaginal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.7' type='checkbox'  value='Per\u00edodos dolorosos \/ irregulares'  id='choice_4_220_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_7' id='label_4_220_7' class='gform-field-label gform-field-label--type-inline'>Per\u00edodos dolorosos \/ irregulares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_220_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.8' type='checkbox'  value='Dificultad sexual'  id='choice_4_220_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_220_8' id='label_4_220_8' class='gform-field-label gform-field-label--type-inline'>Dificultad sexual<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_221\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Psiqui\u00e1trico<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_221'><li class='gchoice gchoice_4_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Depresi\u00f3n'  id='choice_4_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_221_1' id='label_4_221_1' class='gform-field-label gform-field-label--type-inline'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='Ansiedad \/ Nerviosismo'  id='choice_4_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_221_2' id='label_4_221_2' class='gform-field-label gform-field-label--type-inline'>Ansiedad \/ Nerviosismo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_221_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.3' type='checkbox'  value='Trastornos del sue\u00f1o'  id='choice_4_221_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_221_3' id='label_4_221_3' class='gform-field-label gform-field-label--type-inline'>Trastornos del sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_221_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.4' type='checkbox'  value='Pensamientos suicidas'  id='choice_4_221_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_221_4' id='label_4_221_4' class='gform-field-label gform-field-label--type-inline'>Pensamientos suicidas<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_222\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Hematolog\u00eda \/ Linf\u00e1tico<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_222'><li class='gchoice gchoice_4_222_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.1' type='checkbox'  value='Salen hematomas o sangra f\u00e1cilmente'  id='choice_4_222_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_222_1' id='label_4_222_1' class='gform-field-label gform-field-label--type-inline'>Salen hematomas o sangra f\u00e1cilmente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_222_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.2' type='checkbox'  value='Anemia'  id='choice_4_222_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_222_2' id='label_4_222_2' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_222_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.3' type='checkbox'  value='Lento para sanar'  id='choice_4_222_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_222_3' id='label_4_222_3' class='gform-field-label gform-field-label--type-inline'>Lento para sanar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_222_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.4' type='checkbox'  value='Historial de transfusi\u00f3n'  id='choice_4_222_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_222_4' id='label_4_222_4' class='gform-field-label gform-field-label--type-inline'>Historial de transfusi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_223\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Musculoesquel\u00e9tico<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_223'><li class='gchoice gchoice_4_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Dolor o rigidez en las articulaciones'  id='choice_4_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_223_1' id='label_4_223_1' class='gform-field-label gform-field-label--type-inline'>Dolor o rigidez en las articulaciones<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='Dolor de espalda'  id='choice_4_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_223_2' id='label_4_223_2' class='gform-field-label gform-field-label--type-inline'>Dolor de espalda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_223_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.3' type='checkbox'  value='Dolor muscular o calambres'  id='choice_4_223_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_223_3' id='label_4_223_3' class='gform-field-label gform-field-label--type-inline'>Dolor muscular o calambres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_223_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.4' type='checkbox'  value='Brazos o piernas fr\u00edas'  id='choice_4_223_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_223_4' id='label_4_223_4' class='gform-field-label gform-field-label--type-inline'>Brazos o piernas fr\u00edas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_223_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.5' type='checkbox'  value='Dificultad para caminar'  id='choice_4_223_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_223_5' id='label_4_223_5' class='gform-field-label gform-field-label--type-inline'>Dificultad para caminar<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_224\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Piel y Seno<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_224'><li class='gchoice gchoice_4_224_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.1' type='checkbox'  value='Sarpullido o picaz\u00f3n'  id='choice_4_224_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_224_1' id='label_4_224_1' class='gform-field-label gform-field-label--type-inline'>Sarpullido o picaz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_224_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.2' type='checkbox'  value='Lesi\u00f3n o cambio en el color de la piel'  id='choice_4_224_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_224_2' id='label_4_224_2' class='gform-field-label gform-field-label--type-inline'>Lesi\u00f3n o cambio en el color de la piel<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_224_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.3' type='checkbox'  value='Masa mamaria \/ bulto'  id='choice_4_224_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_224_3' id='label_4_224_3' class='gform-field-label gform-field-label--type-inline'>Masa mamaria \/ bulto<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_224_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.4' type='checkbox'  value='Secreci\u00f3n \/ retracci\u00f3n del pez\u00f3n'  id='choice_4_224_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_224_4' id='label_4_224_4' class='gform-field-label gform-field-label--type-inline'>Secreci\u00f3n \/ retracci\u00f3n del pez\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_224_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.5' type='checkbox'  value='Herida abierta o no cicatrizante'  id='choice_4_224_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_224_5' id='label_4_224_5' class='gform-field-label gform-field-label--type-inline'>Herida abierta o no cicatrizante<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_225\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Neurol\u00f3gico<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_225'><li class='gchoice gchoice_4_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Dolor de cabeza frecuente'  id='choice_4_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_1' id='label_4_225_1' class='gform-field-label gform-field-label--type-inline'>Dolor de cabeza frecuente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='V\u00e9rtigo o Mareado'  id='choice_4_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_2' id='label_4_225_2' class='gform-field-label gform-field-label--type-inline'>V\u00e9rtigo o Mareado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.3' type='checkbox'  value='Confusi\u00f3n'  id='choice_4_225_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_3' id='label_4_225_3' class='gform-field-label gform-field-label--type-inline'>Confusi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.4' type='checkbox'  value='Dificultad para hablar'  id='choice_4_225_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_4' id='label_4_225_4' class='gform-field-label gform-field-label--type-inline'>Dificultad para hablar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.5' type='checkbox'  value='Actividad convulsiva'  id='choice_4_225_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_5' id='label_4_225_5' class='gform-field-label gform-field-label--type-inline'>Actividad convulsiva<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.6' type='checkbox'  value='Entumecimiento u hormigueo'  id='choice_4_225_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_6' id='label_4_225_6' class='gform-field-label gform-field-label--type-inline'>Entumecimiento u hormigueo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_225_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.7' type='checkbox'  value='Debilidad en brazos o piernas'  id='choice_4_225_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_225_7' id='label_4_225_7' class='gform-field-label gform-field-label--type-inline'>Debilidad en brazos o piernas<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_375' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_375' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_7' class='gform_page' data-js='page-field-id-375' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_227\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Cuestionario acerca de Depresi\u00f3n<\/h3>\n<p><strong>Durante las <u>\u00faltimas 2 semanas<\/u>, que tan seguido ha tenido molestias debido a los siguientes problemas?<\/strong><\/p><\/li><li id=\"field_4_377\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Poco inter\u00e9s o placer en hacer cosas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_377'>\n\t\t\t<li class='gchoice gchoice_4_377_0'>\n\t\t\t\t<input name='input_377' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_377_0'    \/>\n\t\t\t\t<label for='choice_4_377_0' id='label_4_377_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_377_1'>\n\t\t\t\t<input name='input_377' type='radio' value='Varios d\u00edas'  id='choice_4_377_1'    \/>\n\t\t\t\t<label for='choice_4_377_1' id='label_4_377_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_377_2'>\n\t\t\t\t<input name='input_377' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_377_2'    \/>\n\t\t\t\t<label for='choice_4_377_2' id='label_4_377_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_377_3'>\n\t\t\t\t<input name='input_377' type='radio' value='Casi todos los d\u00edas'  id='choice_4_377_3'    \/>\n\t\t\t\t<label for='choice_4_377_3' id='label_4_377_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_378\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. Se ha sentido deca\u00eddo(a), deprimido(a) o sin esperanzas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_378'>\n\t\t\t<li class='gchoice gchoice_4_378_0'>\n\t\t\t\t<input name='input_378' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_378_0'    \/>\n\t\t\t\t<label for='choice_4_378_0' id='label_4_378_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_378_1'>\n\t\t\t\t<input name='input_378' type='radio' value='Varios d\u00edas'  id='choice_4_378_1'    \/>\n\t\t\t\t<label for='choice_4_378_1' id='label_4_378_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_378_2'>\n\t\t\t\t<input name='input_378' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_378_2'    \/>\n\t\t\t\t<label for='choice_4_378_2' id='label_4_378_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_378_3'>\n\t\t\t\t<input name='input_378' type='radio' value='Casi todos los d\u00edas'  id='choice_4_378_3'    \/>\n\t\t\t\t<label for='choice_4_378_3' id='label_4_378_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_379\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Ha tenido dificultades para quedarse o permanecer  dormido(a), o ha dormido demasiado<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_379'>\n\t\t\t<li class='gchoice gchoice_4_379_0'>\n\t\t\t\t<input name='input_379' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_379_0'    \/>\n\t\t\t\t<label for='choice_4_379_0' id='label_4_379_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_379_1'>\n\t\t\t\t<input name='input_379' type='radio' value='Varios d\u00edas'  id='choice_4_379_1'    \/>\n\t\t\t\t<label for='choice_4_379_1' id='label_4_379_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_379_2'>\n\t\t\t\t<input name='input_379' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_379_2'    \/>\n\t\t\t\t<label for='choice_4_379_2' id='label_4_379_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_379_3'>\n\t\t\t\t<input name='input_379' type='radio' value='Casi todos los d\u00edas'  id='choice_4_379_3'    \/>\n\t\t\t\t<label for='choice_4_379_3' id='label_4_379_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_380\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. Se ha sentido cansado(a) o con poca energ\u00eda<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_380'>\n\t\t\t<li class='gchoice gchoice_4_380_0'>\n\t\t\t\t<input name='input_380' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_380_0'    \/>\n\t\t\t\t<label for='choice_4_380_0' id='label_4_380_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_380_1'>\n\t\t\t\t<input name='input_380' type='radio' value='Varios d\u00edas'  id='choice_4_380_1'    \/>\n\t\t\t\t<label for='choice_4_380_1' id='label_4_380_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_380_2'>\n\t\t\t\t<input name='input_380' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_380_2'    \/>\n\t\t\t\t<label for='choice_4_380_2' id='label_4_380_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_380_3'>\n\t\t\t\t<input name='input_380' type='radio' value='Casi todos los d\u00edas'  id='choice_4_380_3'    \/>\n\t\t\t\t<label for='choice_4_380_3' id='label_4_380_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_381\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. Sin apetito o ha comido en exceso<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_381'>\n\t\t\t<li class='gchoice gchoice_4_381_0'>\n\t\t\t\t<input name='input_381' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_381_0'    \/>\n\t\t\t\t<label for='choice_4_381_0' id='label_4_381_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_381_1'>\n\t\t\t\t<input name='input_381' type='radio' value='Varios d\u00edas'  id='choice_4_381_1'    \/>\n\t\t\t\t<label for='choice_4_381_1' id='label_4_381_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_381_2'>\n\t\t\t\t<input name='input_381' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_381_2'    \/>\n\t\t\t\t<label for='choice_4_381_2' id='label_4_381_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_381_3'>\n\t\t\t\t<input name='input_381' type='radio' value='Casi todos los d\u00edas'  id='choice_4_381_3'    \/>\n\t\t\t\t<label for='choice_4_381_3' id='label_4_381_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_382\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6. Se ha sentido mal con usted mismo(a) - o que es  un fracaso, o que ha quedao mal con usted mismo(a) o con su familia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_382'>\n\t\t\t<li class='gchoice gchoice_4_382_0'>\n\t\t\t\t<input name='input_382' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_382_0'    \/>\n\t\t\t\t<label for='choice_4_382_0' id='label_4_382_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_382_1'>\n\t\t\t\t<input name='input_382' type='radio' value='Varios d\u00edas'  id='choice_4_382_1'    \/>\n\t\t\t\t<label for='choice_4_382_1' id='label_4_382_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_382_2'>\n\t\t\t\t<input name='input_382' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_382_2'    \/>\n\t\t\t\t<label for='choice_4_382_2' id='label_4_382_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_382_3'>\n\t\t\t\t<input name='input_382' type='radio' value='Casi todos los d\u00edas'  id='choice_4_382_3'    \/>\n\t\t\t\t<label for='choice_4_382_3' id='label_4_382_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_383\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >7. Ha tenido dificultad para concentrarse en ciertas actividades, tales como ver el peri\u00f3dico o ver la televisi\u00f3n<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_383'>\n\t\t\t<li class='gchoice gchoice_4_383_0'>\n\t\t\t\t<input name='input_383' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_383_0'    \/>\n\t\t\t\t<label for='choice_4_383_0' id='label_4_383_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_383_1'>\n\t\t\t\t<input name='input_383' type='radio' value='Varios d\u00edas'  id='choice_4_383_1'    \/>\n\t\t\t\t<label for='choice_4_383_1' id='label_4_383_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_383_2'>\n\t\t\t\t<input name='input_383' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_383_2'    \/>\n\t\t\t\t<label for='choice_4_383_2' id='label_4_383_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_383_3'>\n\t\t\t\t<input name='input_383' type='radio' value='Casi todos los d\u00edas'  id='choice_4_383_3'    \/>\n\t\t\t\t<label for='choice_4_383_3' id='label_4_383_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_384\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >8. Se ha movido o hablado tan lento que otras personas podr\u00edan  haberlo notado? O lo contrario - muy inquieto(a) o agitado(a)  que ha estado movi\u00e9ndose mucho m\u00e1s de lo normal<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_384'>\n\t\t\t<li class='gchoice gchoice_4_384_0'>\n\t\t\t\t<input name='input_384' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_384_0'    \/>\n\t\t\t\t<label for='choice_4_384_0' id='label_4_384_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_384_1'>\n\t\t\t\t<input name='input_384' type='radio' value='Varios d\u00edas'  id='choice_4_384_1'    \/>\n\t\t\t\t<label for='choice_4_384_1' id='label_4_384_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_384_2'>\n\t\t\t\t<input name='input_384' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_384_2'    \/>\n\t\t\t\t<label for='choice_4_384_2' id='label_4_384_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_384_3'>\n\t\t\t\t<input name='input_384' type='radio' value='Casi todos los d\u00edas'  id='choice_4_384_3'    \/>\n\t\t\t\t<label for='choice_4_384_3' id='label_4_384_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_385\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >9. Pensamientos de que estar\u00eda mejor muerto(a) o de  lastimarse de alguna manera<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_385'>\n\t\t\t<li class='gchoice gchoice_4_385_0'>\n\t\t\t\t<input name='input_385' type='radio' value='Ning\u00fan d\u00eda'  id='choice_4_385_0'    \/>\n\t\t\t\t<label for='choice_4_385_0' id='label_4_385_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_385_1'>\n\t\t\t\t<input name='input_385' type='radio' value='Varios d\u00edas'  id='choice_4_385_1'    \/>\n\t\t\t\t<label for='choice_4_385_1' id='label_4_385_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_385_2'>\n\t\t\t\t<input name='input_385' type='radio' value='Mas de la mita de los d\u00edas'  id='choice_4_385_2'    \/>\n\t\t\t\t<label for='choice_4_385_2' id='label_4_385_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_385_3'>\n\t\t\t\t<input name='input_385' type='radio' value='Casi todos los d\u00edas'  id='choice_4_385_3'    \/>\n\t\t\t\t<label for='choice_4_385_3' id='label_4_385_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_226' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_226' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_8' class='gform_page' data-js='page-field-id-226' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_376\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Directivas Anticipadas<\/h3><\/li><li id=\"field_4_228\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene un Poder Legal M\u00e9dico?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_228'>\n\t\t\t<li class='gchoice gchoice_4_228_0'>\n\t\t\t\t<input name='input_228' type='radio' value='No'  id='choice_4_228_0'    \/>\n\t\t\t\t<label for='choice_4_228_0' id='label_4_228_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_228_1'>\n\t\t\t\t<input name='input_228' type='radio' value='Si'  id='choice_4_228_1'    \/>\n\t\t\t\t<label for='choice_4_228_1' id='label_4_228_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_229\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene una Directiva Anticipada?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_229'>\n\t\t\t<li class='gchoice gchoice_4_229_0'>\n\t\t\t\t<input name='input_229' type='radio' value='No'  id='choice_4_229_0'    \/>\n\t\t\t\t<label for='choice_4_229_0' id='label_4_229_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_229_1'>\n\t\t\t\t<input name='input_229' type='radio' value='Si'  id='choice_4_229_1'    \/>\n\t\t\t\t<label for='choice_4_229_1' id='label_4_229_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_230\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene un Testamento en Vida?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_230'>\n\t\t\t<li class='gchoice gchoice_4_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_4_230_0'    \/>\n\t\t\t\t<label for='choice_4_230_0' id='label_4_230_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='Si'  id='choice_4_230_1'    \/>\n\t\t\t\t<label for='choice_4_230_1' id='label_4_230_1' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_231\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tiene una tarjeta de donante?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_231'>\n\t\t\t<li class='gchoice gchoice_4_231_0'>\n\t\t\t\t<input name='input_231' type='radio' value='No'  id='choice_4_231_0'    \/>\n\t\t\t\t<label for='choice_4_231_0' id='label_4_231_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_231_1'>\n\t\t\t\t<input name='input_231' type='radio' value='Yes'  id='choice_4_231_1'    \/>\n\t\t\t\t<label for='choice_4_231_1' id='label_4_231_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_232\" class=\"gfield gfield--type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_232'>Si respondi\u00f3 &quot;s\u00ed&quot; a cualquiera de las preguntas anteriores. Favor proporcione una copia del documento.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_232' id='input_4_232' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_232\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_232'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_232'><\/div> <\/div><\/li><li id=\"field_4_233\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Enumere los nombres y las direcciones de los m\u00e9dicos a los que desea que le enviemos la correspondencia:<\/strong><\/li><li id=\"field_4_234\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_234'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_4_234' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_237\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_237'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_237' id='input_4_237' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_236\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_236'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_4_236' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_235\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_235'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_4_235' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_238\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Como paciente usted reconoce que, al completar este formulario, constituye el resumen completo de su historial cl\u00ednico.<\/strong><\/p>\n<p><small>Al ingresar mi nombre, acepto que la firma y las iniciales ser\u00e1n la representaci\u00f3n electr\u00f3nica de mi firma e iniciales para todos los prop\u00f3sitos cuando\n\u00daselos en este formulario, al igual que una firma en l\u00e1piz y papel o una inicial<\/small><\/p><\/li><li id=\"field_4_239\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_239'>Firma del Paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_4_239' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_242\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_242'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_242' id='input_4_242' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_242_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_242_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_242' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_337\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfAcepta firmar electr\u00f3nicamente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_337.1' id='input_4_337_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_337_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_337.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_337.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_243\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_243'>Firma de la Enfermera<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_4_243' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_244\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_244'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_244' id='input_4_244' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_244_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_244_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_244' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_338\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/label><div class='ginput_container ginput_container_consent'><input name='input_338.1' id='input_4_338_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_338_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_338.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_338.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_245\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_245'>Firma del Medico<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_4_245' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_340\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_340'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_340' id='input_4_340' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_340_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_340_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_340' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_339\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/label><div class='ginput_container ginput_container_consent'><input name='input_339.1' id='input_4_339_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_339_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_339.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_339.3' value='2' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_247' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_247' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_9' class='gform_page' data-js='page-field-id-247' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_249\" class=\"gfield gfield--type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Asignaci\u00f3n de Beneficios<\/h3>\n<h3>Responsabilidad Financiera<\/h3>\n<p>Todos los servicios profesionales prestados son responsabilidad del paciente y deben pagarse al momento del servicio; A menos que se hayan hecho otros arreglos por adelantado con nuestra oficina comercial. Deber\u00e1n completarse los formularios necesarios para presentar los pagos de la aseguradora.<\/p>\n<h3>Asignaci\u00f3n de Beneficios<\/h3>\n<p>Por la presente, asigno todos los beneficios m\u00e9dicos y quir\u00fargicos, incluyendo los principales beneficios m\u00e9dicos a los que tengo derecho. Igualmente autorizo y ordeno a mi (s) compa\u00f1\u00eda (s) de seguros, incluidos Medicare, seguro privado y cualquier otro plan m\u00e9dico \/ de salud, a emitir cheques de pago directamente a Advocate Radiation Oncology LLC por los servicios m\u00e9dicos prestados a m\u00ed y \/ o mis dependientes, independientemente de mis beneficios de seguro, si los hay. Entiendo que soy responsable de cualquier monto no cubierto por el seguro.<\/p>\n<h3>Autorizaci\u00f3n para Divulgaci\u00f3n de Informaci\u00f3n<\/h3>\n<p>Por la presente autorizo a Advocate Radiation Oncology LLC a: (1) divulgar cualquier informaci\u00f3n necesaria a las compa\u00f1\u00edas de seguros con respecto a mi enfermedad y tratamientos; (2) procesar los reclamos de seguro generados en el curso del examen o tratamiento; y (3) permitir que se use una fotocopia de mi firma para procesar reclamos de seguro. Esta orden permanecer\u00e1 vigente hasta que sea revocada por m\u00ed por escrito.\nHe solicitado servicios m\u00e9dicos de Advocate Radiation Oncology LLC en nombre m\u00edo y \/ o de mis dependientes, y entiendo que, al hacer esta solicitud, soy completamente responsable financieramente de todos los cargos incurridos en el curso del tratamiento autorizado.\nAdem\u00e1s, entiendo que las tarifas deben pagarse en la fecha en que se prestan los servicios y acepto pagar todos los cargos incurridos en su totalidad inmediatamente despu\u00e9s de la presentaci\u00f3n de la declaraci\u00f3n correspondiente. Una fotocopia de este documento se considerar\u00e1 tan v\u00e1lido como el original\n<\/p><\/li><li id=\"field_4_251\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_251'>Firma del paciente \/ responsable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_251' id='input_4_251' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_250\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_250'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_250' id='input_4_250' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_250_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_250_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_250' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_341\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento para firmar electr\u00f3nicamente.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_341.1' id='input_4_341_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_341_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_341.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_341.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_252\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_252'>Testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_4_252' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_253\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_253'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_253' id='input_4_253' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_253_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_253_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_253' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_342\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento para firmar electr\u00f3nicamente.<\/label><div class='ginput_container ginput_container_consent'><input name='input_342.1' id='input_4_342_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_342_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_342.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_342.3' value='2' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_255' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_255' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_10' class='gform_page' data-js='page-field-id-255' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_254\" class=\"gfield gfield--type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Formulario de Autorizaci\u00f3n de HIPAA para la Divulgaci\u00f3n de Informaci\u00f3n del Paciente<\/h3>\n<h4>ACERCA DE ESTE AVISO<\/h4>\n<p>Entendemos que la informaci\u00f3n sobre su salud es personal y estamos comprometidos a protegerla. Nosotros creamos un registro de la atenci\u00f3n y los servicios que recibe en Advocate Radiation Oncology. Necesitamos este registro para brindarle atenci\u00f3n (tratamiento), para el pago de la atenci\u00f3n brindada, por operaciones de atenci\u00f3n m\u00e9dica y para cumplir con ciertos requisitos legales. Este Aviso le informar\u00e1 sobre las maneras en que podemos usar y divulgar su informaci\u00f3n de salud. Tambi\u00e9n describe sus derechos y ciertas obligaciones que tenemos con respecto al uso y divulgaci\u00f3n de informaci\u00f3n de salud. La ley nos exige que cumplamos con los t\u00e9rminos de este Aviso que est\u00e1 actualmente vigente.<\/p><p>La Ley de Responsabilidad y Portabilidad del Seguro de Salud de 1996 S160.103, tambi\u00e9n conocida como HIPAA, define la informaci\u00f3n de salud personal individual (PHI) como informaci\u00f3n, incluida la informaci\u00f3n demogr\u00e1fica recopilada de un individuo e incluye informaci\u00f3n que es:<\/p>\n<ol>\n<li>Creado o recibido por un proveedor de atenci\u00f3n m\u00e9dica, plan de salud, empleador o centro de compensaci\u00f3n de atenci\u00f3n m\u00e9dica.<\/li>\n<li>Relacionado con la salud f\u00edsica, mental pasada, presente o futura y \/ o la condici\u00f3n de un pago pasado, presente o futuro de un individuo por la prestaci\u00f3n de atenci\u00f3n m\u00e9dica al individuo.<\/li>\n<li>La informaci\u00f3n, por lo tanto, que identifica a un individuo o proporciona una base razonable para creer que la informaci\u00f3n puede usarse para identificar al individuo.<\/li>\n<\/ol>\n<p>La informaci\u00f3n de salud personal (PHI) solo puede divulgarse mediante una autorizaci\u00f3n (S164.502) y ser utilizada por un proveedor de atenci\u00f3n m\u00e9dica de las siguientes maneras:<\/p>\n<ol>\n<li>1.\tPara tratamiento: Podemos usar o divulgar su informaci\u00f3n de salud personal (PHI) para brindarle tratamiento o servicios m\u00e9dicos y para administrar y coordinar su atenci\u00f3n m\u00e9dica. Por ejemplo, su PHI se puede proporcionar a un m\u00e9dico u otro proveedor de atenci\u00f3n m\u00e9dica (por ejemplo, un especialista o laboratorio) a quien se le haya referido para asegurarse de que el m\u00e9dico u otro proveedor de atenci\u00f3n m\u00e9dica tenga la informaci\u00f3n necesaria para diagnosticarlo, tratarlo, o brindarle un servicio. <\/li>\n<li>2.\tPara el pago: podemos usar y divulgar su PHI para poder facturar el tratamiento y los servicios que recibe de nosotros y podemos cobrarle a usted, a un plan de salud o a un tercero.  Este uso y divulgaci\u00f3n pueden incluir ciertas actividades que su plan de seguro m\u00e9dico puede realizar antes de que apruebe o pague los servicios de atenci\u00f3n m\u00e9dica que le recomendamos, como tomar una determinaci\u00f3n de elegibilidad o cobertura para los beneficios del seguro, revisar los servicios que se le brindan para fines de necesidad m\u00e9dica y llevar a cabo actividades de revisi\u00f3n de utilizaci\u00f3n. Por ejemplo, es posible que necesitemos brindarle informaci\u00f3n a su plan de salud sobre su tratamiento para que su plan de salud acepte pagar dicho tratamiento<\/li>\n<li>3.\tPara operaciones de atenci\u00f3n m\u00e9dica: podemos usar y divulgar PHI para nuestras operaciones de atenci\u00f3n m\u00e9dica. Por ejemplo, para revisar internamente la calidad del tratamiento y los servicios que recibe y para evaluar el desempe\u00f1o de los miembros de nuestro equipo en su atenci\u00f3n. Tambi\u00e9n podemos divulgar informaci\u00f3n a m\u00e9dicos, enfermeras, t\u00e9cnicos m\u00e9dicos, estudiantes de medicina y otro personal autorizado con fines educativos y de aprendizaje.<\/li>\n<\/ol>\n<p><small>2. Uso o divulgaci\u00f3n a un representante personal asignado por el paciente.<br>\n3. Divulgaci\u00f3n a los padres o personas que act\u00faan en lugar del padre o madre del menor no emancipado.<br>\n4. Para la administraci\u00f3n de casos, la coordinaci\u00f3n de la atenci\u00f3n para el individuo, para dirigir o recomendar tratamientos o terapias alternas, proveedores de atenci\u00f3n m\u00e9dica o venta de atenci\u00f3n m\u00e9dica. <\/small><\/p><\/li><li id=\"field_4_316\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>HIPAA para la Divulgaci\u00f3n de Informaci\u00f3n del Paciente<\/h3><\/li><li id=\"field_4_310\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >HE LE\u00cdDO EL FORMULARIO DE DIVULGACI\u00d3N AUTORIZADA Y LO ENTIENDO.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_310.1' id='input_4_310_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_310_1' ><p>Entiendo que tengo el derecho de revocar esta autorizaci\u00f3n, por escrito, en cualquier momento, excepto cuando ya se hayan hecho usos o divulgaciones con base en mi permiso original. Es posible que no pueda revocar esta autorizaci\u00f3n si su prop\u00f3sito era obtener un seguro. Para revocar esta autorizaci\u00f3n, debo hacerlo por escrito y enviarla a la parte divulgadora correspondiente.<\/p><p>Entiendo que el uso y divulgaciones que ya se han realizado en base a mi permiso original no se pueden retirar.<\/p><p>Entiendo que es posible que la informaci\u00f3n utilizada o divulgada con mi permiso pueda ser divulgada nuevamente por el destinatario y ya no est\u00e9 protegida por los Est\u00e1ndares de privacidad de HIPAA.<\/p><p>Entiendo que el tratamiento por parte de cualquier parte no puede estar condicionado a mi firma de esta autorizaci\u00f3n (a menos que el tratamiento se busque solo para crear informaci\u00f3n m\u00e9dica para un tercero o para participar en un estudio de investigaci\u00f3n) y que puedo tener derecho a negarme a firmar esta autorizaci\u00f3n.<\/p><p>Recibir\u00e9 una copia de esta autorizaci\u00f3n despu\u00e9s de haberla firmado. Una copia de esta autorizaci\u00f3n es tan v\u00e1lida como el original.<\/p><\/label><input type='hidden' name='input_310.2' value='&lt;p&gt;Entiendo que tengo el derecho de revocar esta autorizaci\u00f3n, por escrito, en cualquier momento, excepto cuando ya se hayan hecho usos o divulgaciones con base en mi permiso original. Es posible que no pueda revocar esta autorizaci\u00f3n si su prop\u00f3sito era obtener un seguro. Para revocar esta autorizaci\u00f3n, debo hacerlo por escrito y enviarla a la parte divulgadora correspondiente.&lt;\/p&gt;&lt;p&gt;Entiendo que el uso y divulgaciones que ya se han realizado en base a mi permiso original no se pueden retirar.&lt;\/p&gt;&lt;p&gt;Entiendo que es posible que la informaci\u00f3n utilizada o divulgada con mi permiso pueda ser divulgada nuevamente por el destinatario y ya no est\u00e9 protegida por los Est\u00e1ndares de privacidad de HIPAA.&lt;\/p&gt;&lt;p&gt;Entiendo que el tratamiento por parte de cualquier parte no puede estar condicionado a mi firma de esta autorizaci\u00f3n (a menos que el tratamiento se busque solo para crear informaci\u00f3n m\u00e9dica para un tercero o para participar en un estudio de investigaci\u00f3n) y que puedo tener derecho a negarme a firmar esta autorizaci\u00f3n.&lt;\/p&gt;&lt;p&gt;Recibir\u00e9 una copia de esta autorizaci\u00f3n despu\u00e9s de haberla firmado. Una copia de esta autorizaci\u00f3n es tan v\u00e1lida como el original.&lt;\/p&gt;' class='gform_hidden' \/><input type='hidden' name='input_310.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_258\" class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_258'>Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_258' id='input_4_258' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_261\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_261'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_261' id='input_4_261' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_261_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_261_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_261' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_345\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_345.1' id='input_4_345_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_345_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_345.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_345.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_260\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_260'>Firma de un Testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_260' id='input_4_260' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_346\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_346'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_346' id='input_4_346' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_346_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_346_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_346' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_364\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/label><div class='ginput_container ginput_container_consent'><input name='input_364.1' id='input_4_364_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_364_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_364.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_364.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_263\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Por la presente autorizo a las siguientes personas a acceder a mi informaci\u00f3n m\u00e9dica en cualquier momento:<\/strong><\/li><li id=\"field_4_264\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_264'>Nombre del Tutor \/ Representante<\/label><div class='ginput_container ginput_container_text'><input name='input_264' id='input_4_264' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_265\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_265'>Relaci\u00f3n Legal<\/label><div class='ginput_container ginput_container_text'><input name='input_265' id='input_4_265' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_268\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_268'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_268' id='input_4_268' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_268_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_268_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_268' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_267\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_267'>Testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_267' id='input_4_267' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_269\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Por la presente autorizo a las siguientes personas a acceder a mi informaci\u00f3n m\u00e9dica en cualquier momento:<\/strong><\/li><li id=\"field_4_270\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_270'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_270' id='input_4_270' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_271\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_271'>Relaci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_271' id='input_4_271' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_272\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_272'>N\u00famero de Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_text'><input name='input_272' id='input_4_272' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_276\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_276' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_276_1_container' >\n                                        <input type='text' name='input_276.1' id='input_4_276_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_276_1' id='input_4_276_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_276_3_container' >\n                                    <input type='text' name='input_276.3' id='input_4_276_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_276_3' id='input_4_276_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_276_4_container' >\n                                        <input type='text' name='input_276.4' id='input_4_276_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_276_4' id='input_4_276_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_276_5_container' >\n                                    <input type='text' name='input_276.5' id='input_4_276_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_276_5' id='input_4_276_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_276.6' id='input_4_276_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_274\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_274'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_274' id='input_4_274' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_275\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_275'>Relaci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_275' id='input_4_275' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_277\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_277'>N\u00famero de Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_text'><input name='input_277' id='input_4_277' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_278\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_278' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_278_1_container' >\n                                        <input type='text' name='input_278.1' id='input_4_278_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_278_1' id='input_4_278_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_278_3_container' >\n                                    <input type='text' name='input_278.3' id='input_4_278_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_278_3' id='input_4_278_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_278_4_container' >\n                                        <input type='text' name='input_278.4' id='input_4_278_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_278_4' id='input_4_278_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_278_5_container' >\n                                    <input type='text' name='input_278.5' id='input_4_278_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_278_5' id='input_4_278_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_278.6' id='input_4_278_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_279\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_279'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_279' id='input_4_279' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_280\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_280'>Relaci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_280' id='input_4_280' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_281\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_281'>N\u00famero de Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_text'><input name='input_281' id='input_4_281' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_282\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_282' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_282_1_container' >\n                                        <input type='text' name='input_282.1' id='input_4_282_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_282_1' id='input_4_282_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_282_3_container' >\n                                    <input type='text' name='input_282.3' id='input_4_282_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_282_3' id='input_4_282_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_282_4_container' >\n                                        <input type='text' name='input_282.4' id='input_4_282_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_282_4' id='input_4_282_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_282_5_container' >\n                                    <input type='text' name='input_282.5' id='input_4_282_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_282_5' id='input_4_282_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_282.6' id='input_4_282_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_283\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_283'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_283' id='input_4_283' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_284\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_284'>Relaci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_284' id='input_4_284' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_285\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_285'>N\u00famero de Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_text'><input name='input_285' id='input_4_285' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_286\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_286' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_286_1_container' >\n                                        <input type='text' name='input_286.1' id='input_4_286_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_286_1' id='input_4_286_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_286_3_container' >\n                                    <input type='text' name='input_286.3' id='input_4_286_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_286_3' id='input_4_286_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_286_4_container' >\n                                        <input type='text' name='input_286.4' id='input_4_286_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_286_4' id='input_4_286_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_286_5_container' >\n                                    <input type='text' name='input_286.5' id='input_4_286_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_286_5' id='input_4_286_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_286.6' id='input_4_286_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_287\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_287'>Firma del Paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_287' id='input_4_287' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_288\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_288'>Fecha:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_288' id='input_4_288' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_288_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_288_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_288' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_344\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_344.1' id='input_4_344_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_344_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_344.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_344.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_289\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_289'>Firma de un Testigo:<\/label><div class='ginput_container ginput_container_text'><input name='input_289' id='input_4_289' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_290\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_290'>Fecha:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_290' id='input_4_290' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_290_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_290_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_290' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_365\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/label><div class='ginput_container ginput_container_consent'><input name='input_365.1' id='input_4_365_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_365_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_365.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_365.3' value='2' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_4_262' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_4_262' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_11' class='gform_page' data-js='page-field-id-262' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_315\" class=\"gfield gfield--type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Formulario de Divulgaci\u00f3n de Registros M\u00e9dicos<\/h3>\n<\/li><li id=\"field_4_291\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_291'>Nombre del Paciente:<\/label><div class='ginput_container ginput_container_text'><input name='input_291' id='input_4_291' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_292\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_292'>Fecha de Nacimiento:<\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_4_292' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_293\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_293'>Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_4_293' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_294\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_294' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_294_1_container' >\n                                        <input type='text' name='input_294.1' id='input_4_294_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_294_1' id='input_4_294_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_294_3_container' >\n                                    <input type='text' name='input_294.3' id='input_4_294_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_294_3' id='input_4_294_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_294_4_container' >\n                                        <input type='text' name='input_294.4' id='input_4_294_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_294_4' id='input_4_294_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_294_5_container' >\n                                    <input type='text' name='input_294.5' id='input_4_294_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_294_5' id='input_4_294_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_294.6' id='input_4_294_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_295\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>1. 1.\tAutorizo el uso o divulgaci\u00f3n de la informaci\u00f3n m\u00e9dica de la persona mencionada anteriormente como se describe a continuaci\u00f3n:<\/strong><\/p>\n<p><strong>2. 2.\tLa siguiente persona u organizaci\u00f3n est\u00e1 autorizada para hacer la divulgaci\u00f3n.: <\/strong><\/p><\/li><li id=\"field_4_296\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_296'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_4_296' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_297\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_297' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_297_1_container' >\n                                        <input type='text' name='input_297.1' id='input_4_297_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_297_1' id='input_4_297_1_label' class='gform-field-label gform-field-label--type-sub'>Calle<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_297_3_container' >\n                                    <input type='text' name='input_297.3' id='input_4_297_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_297_3' id='input_4_297_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_297_4_container' >\n                                        <input type='text' name='input_297.4' id='input_4_297_4' value=''      aria-required='false'    \/>\n                                        <label for='input_4_297_4' id='input_4_297_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_297_5_container' >\n                                    <input type='text' name='input_297.5' id='input_4_297_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_297_5' id='input_4_297_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_297.6' id='input_4_297_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_298\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >3. El tipo y la cantidad de informaci\u00f3n que se utilizar\u00e1 o divulgar\u00e1 es la siguiente: (incluya las fechas cuando corresponda).<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_298'><li class='gchoice gchoice_4_298_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.1' type='checkbox'  value='Todos los registros m\u00e9dicos'  id='choice_4_298_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_1' id='label_4_298_1' class='gform-field-label gform-field-label--type-inline'>Todos los registros m\u00e9dicos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.2' type='checkbox'  value='Informes de consultas'  id='choice_4_298_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_2' id='label_4_298_2' class='gform-field-label gform-field-label--type-inline'>Informes de consultas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.3' type='checkbox'  value='Dosimetr\u00eda \/ F\u00edsica'  id='choice_4_298_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_3' id='label_4_298_3' class='gform-field-label gform-field-label--type-inline'>Dosimetr\u00eda \/ F\u00edsica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.4' type='checkbox'  value='Resultados de laboratorio \/ informes de rayos X'  id='choice_4_298_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_4' id='label_4_298_4' class='gform-field-label gform-field-label--type-inline'>Resultados de laboratorio \/ informes de rayos X<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.5' type='checkbox'  value='Notas de progreso'  id='choice_4_298_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_5' id='label_4_298_5' class='gform-field-label gform-field-label--type-inline'>Notas de progreso<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.6' type='checkbox'  value='Seguimiento'  id='choice_4_298_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_6' id='label_4_298_6' class='gform-field-label gform-field-label--type-inline'>Seguimiento<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_298_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.7' type='checkbox'  value='Otro (favor especifique)'  id='choice_4_298_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_298_7' id='label_4_298_7' class='gform-field-label gform-field-label--type-inline'>Otro (favor especifique)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_300\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>4. Entiendo que la informaci\u00f3n en mis registros m\u00e9dicos puede incluir informaci\u00f3n relacionada con enfermedades de transmisi\u00f3n sexual, s\u00edndrome de inmunodeficiencia adquirida (SIDA) o virus de inmunodeficiencia humana (VIH). Tambi\u00e9n puede incluir informaci\u00f3n sobre servicios de salud mental o temperamental y tratamiento para el abuso de alcohol y drogas.<\/strong><\/p> \n\n<p><strong>5. 5.\tEsta informaci\u00f3n puede ser divulgada y utilizada por la siguiente persona u organizaci\u00f3n.<\/strong><\/p><\/li><li id=\"field_4_368\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Advocate Radiation Oncology LLC<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_368'>\n\t\t\t<li class='gchoice gchoice_4_368_0'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Port Charlotte&lt;\/strong&gt; &lt;br&gt;3080 Harbor Blvd. &lt;br&gt;Port Charlotte, FL 33952 &lt;br&gt;Phone: (941) 883-2199 &lt;br&gt;Fax: (941) 979-5041'  id='choice_4_368_0'    \/>\n\t\t\t\t<label for='choice_4_368_0' id='label_4_368_0' class='gform-field-label gform-field-label--type-inline'><strong>Port Charlotte<\/strong> <br>3080 Harbor Blvd. <br>Port Charlotte, FL 33952 <br>Tel\u00e9fono: (941) 883-2199 <br>Fax: (941) 979-5041<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_1'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Fort Myers&lt;\/strong&gt; &lt;br&gt;15681 New Hampshire Ct. &lt;br&gt;Fort Myers, FL 33908 &lt;br&gt;Phone: (239) 437-1977 &lt;br&gt;Fax: (239) 437-1889'  id='choice_4_368_1'    \/>\n\t\t\t\t<label for='choice_4_368_1' id='label_4_368_1' class='gform-field-label gform-field-label--type-inline'><strong>Fort Myers<\/strong> <br>15681 New Hampshire Ct. <br>Fort Myers, FL 33908 <br>Tel\u00e9fono: (239) 437-1977 <br>Fax: (239) 437-1889<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_2'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Cape Coral&lt;\/strong&gt; &lt;br&gt;909 Del Prado Blvd. S &lt;br&gt;Cape Coral, FL 33990 &lt;br&gt;Phone: (239) 217-8070 &lt;br&gt;Fax: (239) 217-8069'  id='choice_4_368_2'    \/>\n\t\t\t\t<label for='choice_4_368_2' id='label_4_368_2' class='gform-field-label gform-field-label--type-inline'><strong>Cape Coral<\/strong> <br>909 Del Prado Blvd. S <br>Cape Coral, FL 33990 <br>Tel\u00e9fono: (239) 217-8070 <br>Fax: (239) 217-8069<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_3'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Bonita Springs&lt;\/strong&gt; &lt;br&gt;25243 Elementary Way&lt;br&gt;Bonita Spings, FL 34135 &lt;br&gt;Phone: (239) 317-2772 &lt;br&gt;Fax: (239) 676-7637'  id='choice_4_368_3'    \/>\n\t\t\t\t<label for='choice_4_368_3' id='label_4_368_3' class='gform-field-label gform-field-label--type-inline'><strong>Bonita Springs<\/strong> <br>25243 Elementary Way<br>Bonita Spings, FL 34135 <br>Tel\u00e9fono: (239) 317-2772 <br>Fax: (239) 676-7637<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_4'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Naples&lt;\/strong&gt; &lt;br&gt;1775 Davis Blvd. &lt;br&gt;Naples, FL 34102 &lt;br&gt;Phone: (239) 372-2838'  id='choice_4_368_4'    \/>\n\t\t\t\t<label for='choice_4_368_4' id='label_4_368_4' class='gform-field-label gform-field-label--type-inline'><strong>Naples<\/strong> <br>1775 Davis Blvd. <br>Naples, FL 34102 <br>Tel\u00e9fono: (239) 372-2838<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_5'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Bradenton&lt;\/strong&gt; &lt;br&gt;5325 E St Road 64&lt;br&gt;Bradenton, FL 34208 &lt;br&gt;Phone: (941) 220-6263 &lt;br&gt;Fax: (386) 490-9100'  id='choice_4_368_5'    \/>\n\t\t\t\t<label for='choice_4_368_5' id='label_4_368_5' class='gform-field-label gform-field-label--type-inline'><strong>Bradenton<\/strong> <br>5325 E St Road 64<br>Bradenton, FL 34208 <br>Tel\u00e9fono: (941) 220-6263 <br>Fax: (386) 490-9100<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_6'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Tamarac&lt;\/strong&gt; &lt;br&gt;7850 N. University Drive&lt;br&gt;Tamarac, FL 33321 &lt;br&gt;Phone: (754) 205-0099 &lt;br&gt;Fax: (954) 388-5849'  id='choice_4_368_6'    \/>\n\t\t\t\t<label for='choice_4_368_6' id='label_4_368_6' class='gform-field-label gform-field-label--type-inline'><strong>Tamarac<\/strong> <br>7850 N. University Drive<br>Tamarac, FL 33321 <br>Tel\u00e9fono: (754) 205-0099 <br>Fax: (954) 388-5849<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_7'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;West Palm Beach&lt;\/strong&gt; &lt;br&gt;4832 Okeechobee Blvd&lt;br&gt;West Palm Beach, FL 33417 &lt;br&gt;Phone: (561) 277-0786 &lt;br&gt;Fax: (561) 277-0831'  id='choice_4_368_7'    \/>\n\t\t\t\t<label for='choice_4_368_7' id='label_4_368_7' class='gform-field-label gform-field-label--type-inline'><strong>West Palm Beach<\/strong> <br>4832 Okeechobee Blvd.<br>West Palm Beach, FL 33417 <br>Tel\u00e9fono: (561) 277-0786 <br>Fax: (561) 277-0831<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_368_8'>\n\t\t\t\t<input name='input_368' type='radio' value='&lt;strong&gt;Wellen Park&lt;\/strong&gt;&lt;br&gt; 8026 Tamiami Trail&lt;br&gt; Venice, FL 34293-5113&lt;br&gt; Phone (941) 220-6460&lt;br&gt; Fax (941) 220-5284'  id='choice_4_368_8'    \/>\n\t\t\t\t<label for='choice_4_368_8' id='label_4_368_8' class='gform-field-label gform-field-label--type-inline'><strong>Wellen Park<\/strong><br> 8026 Tamiami Trail<br> Venice, FL 34293-5113<br> Phone (941) 220-6460<br> Fax (941) 220-5284<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_302\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_302'>Con el prop\u00f3sito de:<\/label><div class='ginput_container ginput_container_text'><input name='input_302' id='input_4_302' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_303\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_303'>6. 6.\tEntiendo que tengo derecho a revocar esta autorizaci\u00f3n en cualquier momento. Entiendo que si revoco esta autorizaci\u00f3n debo hacerlo por escrito y presentar mi revocaci\u00f3n por escrito al departamento de administraci\u00f3n de informaci\u00f3n m\u00e9dica. Entiendo que la revocaci\u00f3n no se aplicar\u00e1 a mi compa\u00f1\u00eda de seguros cuando la ley le otorgue a mi aseguradora el derecho a impugnar un reclamo bajo mi p\u00f3liza. A menos que se revoque de otra manera, esta autorizaci\u00f3n vencer\u00e1 en la siguiente fecha, evento o condici\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_4_303' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_305\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>7. 7.\tSi no especifico una fecha de vencimiento, evento o condici\u00f3n, esta autorizaci\u00f3n vencer\u00e1 en un a\u00f1o. Entiendo que autorizar la divulgaci\u00f3n de esta informaci\u00f3n m\u00e9dica es voluntario. Puedo negarme a firmar esta autorizaci\u00f3n. No necesito firmar este formulario para asegurar el tratamiento. Entiendo que puedo inspeccionar o copiar la informaci\u00f3n que se utilizar\u00e1 o divulgar\u00e1, seg\u00fan lo dispuesto en CFR 164.524. Entiendo que cualquier divulgaci\u00f3n de informaci\u00f3n conlleva la posibilidad de una nueva divulgaci\u00f3n no autorizada y es posible que la informaci\u00f3n no est\u00e9 protegida por las reglas federales de confidencialidad. Si tengo preguntas sobre la divulgaci\u00f3n de mi informaci\u00f3n m\u00e9dica, puedo contactar a un representante de la cl\u00ednica en cualquiera de las oficinas de Advocate Radiation Oncology. <\/strong><\/p><\/li><li id=\"field_4_306\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_306'>Firma del paciente o representante legal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_306' id='input_4_306' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_309\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_309'>Fecha:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_309' id='input_4_309' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_309_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_309_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_309' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_347\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_347.1' id='input_4_347_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_347_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_347.2' value='S\u00ed, acepto firmar electr\u00f3nicamente.' class='gform_hidden' \/><input type='hidden' name='input_347.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_4_307\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_307'>Nombre impreso del representante y relaci\u00f3n con el paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_307' id='input_4_307' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_4' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='OGsMBrZ6+jX19hvvnG5o6P6NU4Wi4ZpE5nOhmHOmp8i8hHoHAS25dvnsKPUsCtv\/ST+FhvB2EoPuvBMRZOe+QeoFeqoAlqrBgv7Q5o5vww9Grnc=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' 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