{"id":386,"date":"2018-02-01T15:55:03","date_gmt":"2018-02-01T21:55:03","guid":{"rendered":"http:\/\/fawstudio-dev.site\/2017\/dreduardo\/?page_id=386"},"modified":"2018-02-02T19:15:25","modified_gmt":"2018-02-03T01:15:25","slug":"cuestionario-espanol","status":"publish","type":"page","link":"https:\/\/dreduardo.com.mx\/en\/cuestionario-espanol\/","title":{"rendered":"Cuestionario Espa\u00f1ol"},"content":{"rendered":"[mk_page_section bg_image=&#8221;http:\/\/dreduardo.com.mx\/wp-content\/uploads\/2017\/11\/bg_nosotros.jpg&#8221; bg_position=&#8221;center center&#8221; bg_repeat=&#8221;no-repeat&#8221; bg_stretch=&#8221;true&#8221; video_color_mask=&#8221;#dde9e4&#8243; video_opacity=&#8221;0.3&#8243; min_height=&#8221;300&#8243; sidebar=&#8221;sidebar-1&#8243;][vc_column el_class=&#8221;bloque-cuestionario&#8221;][mk_fancy_title color=&#8221;#ffffff&#8221; size=&#8221;40&#8243; font_weight=&#8221;300&#8243; margin_top=&#8221;100&#8243; font_family=&#8221;Open+Sans&#8221; font_type=&#8221;google&#8221; align=&#8221;center&#8221;]\n<p class=\"p1\"><span class=\"s1\">Cuestionario<\/span><\/p>\n[\/mk_fancy_title][vc_column_text css=&#8221;.vc_custom_1517593060549{margin-bottom: 0px !important;}&#8221;]El prop\u00f3sito de este cuestionario es tener informaci\u00f3n espec\u00edfica sobre su historial cl\u00ednico y as\u00ed poder evaluar su actual Estado de salud. Esta informaci\u00f3n es vital para nosotros porque nos da la oportunidad de formular una preparaci\u00f3n preoperatoria \u00fanica con el fin de ofrecerle el mejor y m\u00e1s seguro procedimiento de reducci\u00f3n de peso, as\u00ed que trate de responderlo lo antes m\u00e1s posible.[\/vc_column_text][\/vc_column][\/mk_page_section][mk_page_section bg_color=&#8221;#f3f9f9&#8243; sidebar=&#8221;sidebar-1&#8243;][vc_column][vc_row_inner is_fullwidth_content=&#8221;false&#8221; el_id=&#8221;cuestionario-forma&#8221;][vc_column_inner]\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_1' style='display:none'><a id='gf_1' class='gform_anchor' ><\/a><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/386#gf_1'>\n                        <div class='gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Informaci\u00f3n del contacto.<\/h3><\/li><li id='field_1_10' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_10' >Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'  tabindex='1'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_3' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_3' >Correo Electronico:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='text' value='' class='medium' tabindex='2'     aria-invalid=\"false\"\/>\n                        <\/div><\/li><li id='field_1_4' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_4' >Celular<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='text' value='' class='medium' tabindex='3'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_5' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_5' >Tel\u00e9fono de casa<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='text' value='' class='medium' tabindex='4'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_8' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_8' >Mejor horario para llamada<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'  tabindex='5'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_7' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_7' >Tel\u00e9fono de trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_1_7' type='text' value='' class='medium' tabindex='6'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_9' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_9' >Zona horaria<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'  tabindex='7'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_11' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_11' >Ciudad<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'  tabindex='8'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_12' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_12' >Estado\/provincia<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'  tabindex='9'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_13' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_13' >Pa\u00eds<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'  tabindex='10'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_14' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_14' >Nombre y tel\u00e9fono del contacto de emergencia<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='medium'  tabindex='11'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_15' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_15' >Acompa\u00f1antes<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'  tabindex='12'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_21' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Informaci\u00f3n personal.<\/h3><\/li><li id='field_1_26' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_26' >Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='medium'  tabindex='13'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_23' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_23' >Edad<\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_1_23' type='text'    value='' class='medium' tabindex='14'      aria-invalid=\"false\"\/><\/div><\/li><li id='field_1_25' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gerero<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_25'><li class='gchoice_1_25_0'><input name='input_25' type='radio' value='Masculino'  id='choice_1_25_0' tabindex='15'  onclick='gf_apply_rules(1,[40]);' onkeypress='gf_apply_rules(1,[40]);'  \/><label for='choice_1_25_0' id='label_1_25_0'>Masculino<\/label><\/li><li class='gchoice_1_25_1'><input name='input_25' type='radio' value='Femenino'  id='choice_1_25_1' tabindex='16'  onclick='gf_apply_rules(1,[40]);' onkeypress='gf_apply_rules(1,[40]);'  \/><label for='choice_1_25_1' id='label_1_25_1'>Femenino<\/label><\/li><\/ul><\/div><\/li><li id='field_1_28' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_28' >Peso<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='medium'  tabindex='17'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_29' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_29' >Altura<\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_1_29' type='text'    value='' class='medium' tabindex='18'      aria-invalid=\"false\"\/><\/div><\/li><li id='field_1_32' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_32' >\u00cdndice de masa corporal<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='medium'  tabindex='19'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_33' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_33' >Fecha de nacimiento<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_1_33' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='20'  \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_33' class='gform_hidden' value='https:\/\/dreduardo.com.mx\/wp-content\/plugins\/gravityforms%202\/images\/calendar.png'\/><\/li><li id='field_1_34' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_34' >Lenguaje<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='medium'  tabindex='21'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_35' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Estructura familiar.<\/h3><\/li><li id='field_1_36' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_36' >Estado civil<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='medium'  tabindex='22'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_37' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_37' >Hijos<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='medium'  tabindex='23'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_40' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_40' >Embarazos\/partos\/abortos<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_1_40' type='text' value='' class='medium'  tabindex='24'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_41' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Informaci\u00f3n laboral.<\/h3><\/li><li id='field_1_44' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfEst\u00e1 usted actualmente empleado\/desempleado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_44'><li class='gchoice_1_44_0'><input name='input_44' type='radio' value='Empleado'  id='choice_1_44_0' tabindex='25'    \/><label for='choice_1_44_0' id='label_1_44_0'>Empleado<\/label><\/li><li class='gchoice_1_44_1'><input name='input_44' type='radio' value='Desempleado'  id='choice_1_44_1' tabindex='26'    \/><label for='choice_1_44_1' id='label_1_44_1'>Desempleado<\/label><\/li><\/ul><\/div><\/li><li id='field_1_45' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfEs su peso un impedimento para encontrar empleo o realizar su trabajo actual?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'><li class='gchoice_1_45_0'><input name='input_45' type='radio' value='Si'  id='choice_1_45_0' tabindex='27'    \/><label for='choice_1_45_0' id='label_1_45_0'>Si<\/label><\/li><li class='gchoice_1_45_1'><input name='input_45' type='radio' value='No'  id='choice_1_45_1' tabindex='28'    \/><label for='choice_1_45_1' id='label_1_45_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_46' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_46' >\u00bfCu\u00e1l es su ocupaci\u00f3n?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='medium'  tabindex='29'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_47' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfTrabaja medio tiempo\/tiempo completo?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_47'><li class='gchoice_1_47_0'><input name='input_47' type='radio' value='Medio tiempo'  id='choice_1_47_0' tabindex='30'    \/><label for='choice_1_47_0' id='label_1_47_0'>Medio tiempo<\/label><\/li><li class='gchoice_1_47_1'><input name='input_47' type='radio' value='Tiempo completo'  id='choice_1_47_1' tabindex='31'    \/><label for='choice_1_47_1' id='label_1_47_1'>Tiempo completo<\/label><\/li><\/ul><\/div><\/li><li id='field_1_48' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_48' >\u00bfQu\u00e9 nivel de actividad requiere su empleo?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='medium'  tabindex='32'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_49' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Cirug\u00eda.<\/h3><\/li><li id='field_1_50' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_50' >\u00bfEn qu\u00e9 tipo de procedimiento est\u00e1 interesado?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='medium'  tabindex='33'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_52' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_52' >Fecha deseada de cirug\u00eda<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_1_52' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='34'  \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_52' class='gform_hidden' value='https:\/\/dreduardo.com.mx\/wp-content\/plugins\/gravityforms%202\/images\/calendar.png'\/><\/li><li id='field_1_51' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_51' >En caso de no disponibilidad, \u00bfqu\u00e9 otra fecha le gustar\u00eda?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='medium'  tabindex='35'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_53' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfHa tenido cirug\u00eda de obesidad previamente?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_53'><li class='gchoice_1_53_0'><input name='input_53' type='radio' value='Si'  id='choice_1_53_0' tabindex='36'    \/><label for='choice_1_53_0' id='label_1_53_0'>Si<\/label><\/li><li class='gchoice_1_53_1'><input name='input_53' type='radio' value='No'  id='choice_1_53_1' tabindex='37'    \/><label for='choice_1_53_1' id='label_1_53_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_54' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_54' >\u00bfCu\u00e1ndo fue realizada?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='medium'  tabindex='38'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_55' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_55' >\u00bfQu\u00e9 tipo de procedimiento?<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='medium'  tabindex='39'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_56' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_56' >\u00bfFue cirug\u00eda abierta (una incisi\u00f3n grande) o laparosc\u00f3pica (varias incisiones peque\u00f1as)?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='medium'  tabindex='40'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_57' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Alergias\/drogas..<\/h3><\/li><li id='field_1_58' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfConsume alcohol?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_58'><li class='gchoice_1_58_0'><input name='input_58' type='radio' value='Si'  id='choice_1_58_0' tabindex='41'    \/><label for='choice_1_58_0' id='label_1_58_0'>Si<\/label><\/li><li class='gchoice_1_58_1'><input name='input_58' type='radio' value='No'  id='choice_1_58_1' tabindex='42'    \/><label for='choice_1_58_1' id='label_1_58_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_60' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_60' >\u00bfQu\u00e9 tipo de alcohol consume?<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='medium'  tabindex='43'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_59' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfUsted fuma?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_59'><li class='gchoice_1_59_0'><input name='input_59' type='radio' value='Si'  id='choice_1_59_0' tabindex='44'  onclick='gf_apply_rules(1,[61,62]);' onkeypress='gf_apply_rules(1,[61,62]);'  \/><label for='choice_1_59_0' id='label_1_59_0'>Si<\/label><\/li><li class='gchoice_1_59_1'><input name='input_59' type='radio' value='No'  id='choice_1_59_1' tabindex='45'  onclick='gf_apply_rules(1,[61,62]);' onkeypress='gf_apply_rules(1,[61,62]);'  \/><label for='choice_1_59_1' id='label_1_59_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_61' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_61' >\u00bfCu\u00e1ntos cigarros al d\u00eda?<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='medium'  tabindex='46'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_62' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_62' >\u00bfPor cu\u00e1nto tiempo?<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='medium'  tabindex='47'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_63' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_63' >\u00bfHace cu\u00e1nto tiempo dej\u00f3 de fumar?<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_1_63' type='text' value='' class='medium'  tabindex='48'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_64' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfConsume drogas?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_64'><li class='gchoice_1_64_0'><input name='input_64' type='radio' value='Si'  id='choice_1_64_0' tabindex='49'  onclick='gf_apply_rules(1,[65]);' onkeypress='gf_apply_rules(1,[65]);'  \/><label for='choice_1_64_0' id='label_1_64_0'>Si<\/label><\/li><li class='gchoice_1_64_1'><input name='input_64' type='radio' value='No'  id='choice_1_64_1' tabindex='50'  onclick='gf_apply_rules(1,[65]);' onkeypress='gf_apply_rules(1,[65]);'  \/><label for='choice_1_64_1' id='label_1_64_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_65' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_65' >\u00bfQu\u00e9 tipo de drogas consume?<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='medium'  tabindex='51'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_66' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfEs al\u00e9rgico a medicamentos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_66'><li class='gchoice_1_66_0'><input name='input_66' type='radio' value='Si'  id='choice_1_66_0' tabindex='52'  onclick='gf_apply_rules(1,[67,68]);' onkeypress='gf_apply_rules(1,[67,68]);'  \/><label for='choice_1_66_0' id='label_1_66_0'>Si<\/label><\/li><li class='gchoice_1_66_1'><input name='input_66' type='radio' value='No'  id='choice_1_66_1' tabindex='53'  onclick='gf_apply_rules(1,[67,68]);' onkeypress='gf_apply_rules(1,[67,68]);'  \/><label for='choice_1_66_1' id='label_1_66_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_67' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_67' >Por favor especifique a qu\u00e9 medicamentos es al\u00e9rgico<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='medium'  tabindex='54'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_68' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_68' >Por favor especifique qu\u00e9 tipo de reacci\u00f3n tiene (salpullido, anafilaxis, comez\u00f3n)<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='medium'  tabindex='55'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_69' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfTiene alergias a alimentos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_69'><li class='gchoice_1_69_0'><input name='input_69' type='radio' value='Si'  id='choice_1_69_0' tabindex='56'    \/><label for='choice_1_69_0' id='label_1_69_0'>Si<\/label><\/li><li class='gchoice_1_69_1'><input name='input_69' type='radio' value='No'  id='choice_1_69_1' tabindex='57'    \/><label for='choice_1_69_1' id='label_1_69_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_70' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfEs usted al\u00e9rgico al l\u00e1tex?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_70'><li class='gchoice_1_70_0'><input name='input_70' type='radio' value='Si'  id='choice_1_70_0' tabindex='58'    \/><label for='choice_1_70_0' id='label_1_70_0'>Si<\/label><\/li><li class='gchoice_1_70_1'><input name='input_70' type='radio' value='No'  id='choice_1_70_1' tabindex='59'    \/><label for='choice_1_70_1' id='label_1_70_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_71' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Apnea obstructiva del sue\u00f1o.<\/h3><\/li><li id='field_1_72' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_72' >\u00bfCu\u00e1ntas horas duerme por la noche?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='medium'  tabindex='60'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_73' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfUsted ronca?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_73'><li class='gchoice_1_73_0'><input name='input_73' type='radio' value='Si'  id='choice_1_73_0' tabindex='61'    \/><label for='choice_1_73_0' id='label_1_73_0'>Si<\/label><\/li><li class='gchoice_1_73_1'><input name='input_73' type='radio' value='No'  id='choice_1_73_1' tabindex='62'    \/><label for='choice_1_73_1' id='label_1_73_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_74' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfLe han comentado que deja de respirar durante la noche?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_74'><li class='gchoice_1_74_0'><input name='input_74' type='radio' value='Si'  id='choice_1_74_0' tabindex='63'    \/><label for='choice_1_74_0' id='label_1_74_0'>Si<\/label><\/li><li class='gchoice_1_74_1'><input name='input_74' type='radio' value='No'  id='choice_1_74_1' tabindex='64'    \/><label for='choice_1_74_1' id='label_1_74_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_75' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfSe siente cansado durante el d\u00eda?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_75'><li class='gchoice_1_75_0'><input name='input_75' type='radio' value='Si'  id='choice_1_75_0' tabindex='65'    \/><label for='choice_1_75_0' id='label_1_75_0'>Si<\/label><\/li><li class='gchoice_1_75_1'><input name='input_75' type='radio' value='No'  id='choice_1_75_1' tabindex='66'    \/><label for='choice_1_75_1' id='label_1_75_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_76' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfSe queda dormido durante el d\u00eda?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_76'><li class='gchoice_1_76_0'><input name='input_76' type='radio' value='Si'  id='choice_1_76_0' tabindex='67'    \/><label for='choice_1_76_0' id='label_1_76_0'>Si<\/label><\/li><li class='gchoice_1_76_1'><input name='input_76' type='radio' value='No'  id='choice_1_76_1' tabindex='68'    \/><label for='choice_1_76_1' id='label_1_76_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_77' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfUtiliza usted una m\u00e1quina CPAP?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_77'><li class='gchoice_1_77_0'><input name='input_77' type='radio' value='Si'  id='choice_1_77_0' tabindex='69'    \/><label for='choice_1_77_0' id='label_1_77_0'>Si<\/label><\/li><li class='gchoice_1_77_1'><input name='input_77' type='radio' value='No'  id='choice_1_77_1' tabindex='70'    \/><label for='choice_1_77_1' id='label_1_77_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_78' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Reflujo gastroesof\u00e1gico.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_79' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfSufre de reflujo?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_79'><li class='gchoice_1_79_0'><input name='input_79' type='radio' value='Si'  id='choice_1_79_0' tabindex='71'    \/><label for='choice_1_79_0' id='label_1_79_0'>Si<\/label><\/li><li class='gchoice_1_79_1'><input name='input_79' type='radio' value='No'  id='choice_1_79_1' tabindex='72'    \/><label for='choice_1_79_1' id='label_1_79_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_80' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_80' >Frecuencia<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='medium'  tabindex='73'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_81' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_81' >\u00bfQu\u00e9 agravia los s\u00edntomas?<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_1_81' type='text' value='' class='medium'  tabindex='74'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_83' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfTiene reflujo durante la noche?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_83'><li class='gchoice_1_83_0'><input name='input_83' type='radio' value='Si'  id='choice_1_83_0' tabindex='75'    \/><label for='choice_1_83_0' id='label_1_83_0'>Si<\/label><\/li><li class='gchoice_1_83_1'><input name='input_83' type='radio' value='No'  id='choice_1_83_1' tabindex='76'    \/><label for='choice_1_83_1' id='label_1_83_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_84' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfTiene voz ronca?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_84'><li class='gchoice_1_84_0'><input name='input_84' type='radio' value='Si'  id='choice_1_84_0' tabindex='77'    \/><label for='choice_1_84_0' id='label_1_84_0'>Si<\/label><\/li><li class='gchoice_1_84_1'><input name='input_84' type='radio' value='No'  id='choice_1_84_1' tabindex='78'    \/><label for='choice_1_84_1' id='label_1_84_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_85' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfPadece de dolor de garganta frecuente?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'><li class='gchoice_1_85_0'><input name='input_85' type='radio' value='Si'  id='choice_1_85_0' tabindex='79'    \/><label for='choice_1_85_0' id='label_1_85_0'>Si<\/label><\/li><li class='gchoice_1_85_1'><input name='input_85' type='radio' value='No'  id='choice_1_85_1' tabindex='80'    \/><label for='choice_1_85_1' id='label_1_85_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_86' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfPadece de asma o s\u00edntomas de asma?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_86'><li class='gchoice_1_86_0'><input name='input_86' type='radio' value='Si'  id='choice_1_86_0' tabindex='81'    \/><label for='choice_1_86_0' id='label_1_86_0'>Si<\/label><\/li><li class='gchoice_1_86_1'><input name='input_86' type='radio' value='No'  id='choice_1_86_1' tabindex='82'    \/><label for='choice_1_86_1' id='label_1_86_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_87' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u00bfPadece de infecciones respiratorias frecuentes?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'><li class='gchoice_1_87_0'><input name='input_87' type='radio' value='Si'  id='choice_1_87_0' tabindex='83'    \/><label for='choice_1_87_0' id='label_1_87_0'>Si<\/label><\/li><li class='gchoice_1_87_1'><input name='input_87' type='radio' value='No'  id='choice_1_87_1' tabindex='84'    \/><label for='choice_1_87_1' id='label_1_87_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_88' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_88' >Medicamentos<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='medium'  tabindex='85'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_89' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Cardiovascular.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_90' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Dificultad para respirar<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_90'><li class='gchoice_1_90_0'><input name='input_90' type='radio' value='Si'  id='choice_1_90_0' tabindex='86'    \/><label for='choice_1_90_0' id='label_1_90_0'>Si<\/label><\/li><li class='gchoice_1_90_1'><input name='input_90' type='radio' value='No'  id='choice_1_90_1' tabindex='87'    \/><label for='choice_1_90_1' id='label_1_90_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_91' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Dolor tor\u00e1cico<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_91'><li class='gchoice_1_91_0'><input name='input_91' type='radio' value='Si'  id='choice_1_91_0' tabindex='88'    \/><label for='choice_1_91_0' id='label_1_91_0'>Si<\/label><\/li><li class='gchoice_1_91_1'><input name='input_91' type='radio' value='No'  id='choice_1_91_1' tabindex='89'    \/><label for='choice_1_91_1' id='label_1_91_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_92' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >S\u00edncope<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_92'><li class='gchoice_1_92_0'><input name='input_92' type='radio' value='Si'  id='choice_1_92_0' tabindex='90'    \/><label for='choice_1_92_0' id='label_1_92_0'>Si<\/label><\/li><li class='gchoice_1_92_1'><input name='input_92' type='radio' value='No'  id='choice_1_92_1' tabindex='91'    \/><label for='choice_1_92_1' id='label_1_92_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_93' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Desmayos<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_93'><li class='gchoice_1_93_0'><input name='input_93' type='radio' value='Si'  id='choice_1_93_0' tabindex='92'    \/><label for='choice_1_93_0' id='label_1_93_0'>Si<\/label><\/li><li class='gchoice_1_93_1'><input name='input_93' type='radio' value='No'  id='choice_1_93_1' tabindex='93'    \/><label for='choice_1_93_1' id='label_1_93_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_94' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cansancio durante actividades diarias o con m\u00ednimo esfuerzo<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_94'><li class='gchoice_1_94_0'><input name='input_94' type='radio' value='Si'  id='choice_1_94_0' tabindex='94'    \/><label for='choice_1_94_0' id='label_1_94_0'>Si<\/label><\/li><li class='gchoice_1_94_1'><input name='input_94' type='radio' value='No'  id='choice_1_94_1' tabindex='95'    \/><label for='choice_1_94_1' id='label_1_94_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_95' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hipertensi\u00f3n<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_95'><li class='gchoice_1_95_0'><input name='input_95' type='radio' value='Si'  id='choice_1_95_0' tabindex='96'    \/><label for='choice_1_95_0' id='label_1_95_0'>Si<\/label><\/li><li class='gchoice_1_95_1'><input name='input_95' type='radio' value='No'  id='choice_1_95_1' tabindex='97'    \/><label for='choice_1_95_1' id='label_1_95_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_96' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Infarto<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_96'><li class='gchoice_1_96_0'><input name='input_96' type='radio' value='Si'  id='choice_1_96_0' tabindex='98'    \/><label for='choice_1_96_0' id='label_1_96_0'>Si<\/label><\/li><li class='gchoice_1_96_1'><input name='input_96' type='radio' value='No'  id='choice_1_96_1' tabindex='99'    \/><label for='choice_1_96_1' id='label_1_96_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_97' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cirug\u00edas cardiacas o cateterismo<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_97'><li class='gchoice_1_97_0'><input name='input_97' type='radio' value='Si'  id='choice_1_97_0' tabindex='100'    \/><label for='choice_1_97_0' id='label_1_97_0'>Si<\/label><\/li><li class='gchoice_1_97_1'><input name='input_97' type='radio' value='No'  id='choice_1_97_1' tabindex='101'    \/><label for='choice_1_97_1' id='label_1_97_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_98' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Trombosis venosa profunda<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_98'><li class='gchoice_1_98_0'><input name='input_98' type='radio' value='Si'  id='choice_1_98_0' tabindex='102'    \/><label for='choice_1_98_0' id='label_1_98_0'>Si<\/label><\/li><li class='gchoice_1_98_1'><input name='input_98' type='radio' value='No'  id='choice_1_98_1' tabindex='103'    \/><label for='choice_1_98_1' id='label_1_98_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_99' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Trombo embolismo pulmonar<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_99'><li class='gchoice_1_99_0'><input name='input_99' type='radio' value='Si'  id='choice_1_99_0' tabindex='104'    \/><label for='choice_1_99_0' id='label_1_99_0'>Si<\/label><\/li><li class='gchoice_1_99_1'><input name='input_99' type='radio' value='No'  id='choice_1_99_1' tabindex='105'    \/><label for='choice_1_99_1' id='label_1_99_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_100' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Varices<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_100'><li class='gchoice_1_100_0'><input name='input_100' type='radio' value='Si'  id='choice_1_100_0' tabindex='106'    \/><label for='choice_1_100_0' id='label_1_100_0'>Si<\/label><\/li><li class='gchoice_1_100_1'><input name='input_100' type='radio' value='No'  id='choice_1_100_1' tabindex='107'    \/><label for='choice_1_100_1' id='label_1_100_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_101' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_101' >Medicamentos<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_1_101' type='text' value='' class='medium'  tabindex='108'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_102' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Metab\u00f3lico \/ reum\u00e1tico.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_103' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_103'><li class='gchoice_1_103_0'><input name='input_103' type='radio' value='Si'  id='choice_1_103_0' tabindex='109'    \/><label for='choice_1_103_0' id='label_1_103_0'>Si<\/label><\/li><li class='gchoice_1_103_1'><input name='input_103' type='radio' value='No'  id='choice_1_103_1' tabindex='110'    \/><label for='choice_1_103_1' id='label_1_103_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_104' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Triglic\u00e9ridos elevados en sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_104'><li class='gchoice_1_104_0'><input name='input_104' type='radio' value='Si'  id='choice_1_104_0' tabindex='111'    \/><label for='choice_1_104_0' id='label_1_104_0'>Si<\/label><\/li><li class='gchoice_1_104_1'><input name='input_104' type='radio' value='No'  id='choice_1_104_1' tabindex='112'    \/><label for='choice_1_104_1' id='label_1_104_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_105' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Colesterol elevado en sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_105'><li class='gchoice_1_105_0'><input name='input_105' type='radio' value='Si'  id='choice_1_105_0' tabindex='113'    \/><label for='choice_1_105_0' id='label_1_105_0'>Si<\/label><\/li><li class='gchoice_1_105_1'><input name='input_105' type='radio' value='No'  id='choice_1_105_1' tabindex='114'    \/><label for='choice_1_105_1' id='label_1_105_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_106' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hipo\/hipertiroidismo<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_106'><li class='gchoice_1_106_0'><input name='input_106' type='radio' value='Si'  id='choice_1_106_0' tabindex='115'    \/><label for='choice_1_106_0' id='label_1_106_0'>Si<\/label><\/li><li class='gchoice_1_106_1'><input name='input_106' type='radio' value='No'  id='choice_1_106_1' tabindex='116'    \/><label for='choice_1_106_1' id='label_1_106_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_107' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gota<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_107'><li class='gchoice_1_107_0'><input name='input_107' type='radio' value='Si'  id='choice_1_107_0' tabindex='117'    \/><label for='choice_1_107_0' id='label_1_107_0'>Si<\/label><\/li><li class='gchoice_1_107_1'><input name='input_107' type='radio' value='No'  id='choice_1_107_1' tabindex='118'    \/><label for='choice_1_107_1' id='label_1_107_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_109' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Artritis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_109'><li class='gchoice_1_109_0'><input name='input_109' type='radio' value='Si'  id='choice_1_109_0' tabindex='119'    \/><label for='choice_1_109_0' id='label_1_109_0'>Si<\/label><\/li><li class='gchoice_1_109_1'><input name='input_109' type='radio' value='No'  id='choice_1_109_1' tabindex='120'    \/><label for='choice_1_109_1' id='label_1_109_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_108' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Lupus<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_108'><li class='gchoice_1_108_0'><input name='input_108' type='radio' value='Si'  id='choice_1_108_0' tabindex='121'    \/><label for='choice_1_108_0' id='label_1_108_0'>Si<\/label><\/li><li class='gchoice_1_108_1'><input name='input_108' type='radio' value='No'  id='choice_1_108_1' tabindex='122'    \/><label for='choice_1_108_1' id='label_1_108_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_110' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Fibromialgia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_110'><li class='gchoice_1_110_0'><input name='input_110' type='radio' value='Si'  id='choice_1_110_0' tabindex='123'    \/><label for='choice_1_110_0' id='label_1_110_0'>Si<\/label><\/li><li class='gchoice_1_110_1'><input name='input_110' type='radio' value='No'  id='choice_1_110_1' tabindex='124'    \/><label for='choice_1_110_1' id='label_1_110_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_111' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >S\u00edndrome anti fosfol\u00edpido<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_111'><li class='gchoice_1_111_0'><input name='input_111' type='radio' value='Si'  id='choice_1_111_0' tabindex='125'    \/><label for='choice_1_111_0' id='label_1_111_0'>Si<\/label><\/li><li class='gchoice_1_111_1'><input name='input_111' type='radio' value='No'  id='choice_1_111_1' tabindex='126'    \/><label for='choice_1_111_1' id='label_1_111_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_112' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Otros<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_112'><li class='gchoice_1_112_0'><input name='input_112' type='radio' value='Si'  id='choice_1_112_0' tabindex='127'    \/><label for='choice_1_112_0' id='label_1_112_0'>Si<\/label><\/li><li class='gchoice_1_112_1'><input name='input_112' type='radio' value='No'  id='choice_1_112_1' tabindex='128'    \/><label for='choice_1_112_1' id='label_1_112_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_113' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Medicamentos<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_113'><li class='gchoice_1_113_0'><input name='input_113' type='radio' value='Si'  id='choice_1_113_0' tabindex='129'    \/><label for='choice_1_113_0' id='label_1_113_0'>Si<\/label><\/li><li class='gchoice_1_113_1'><input name='input_113' type='radio' value='No'  id='choice_1_113_1' tabindex='130'    \/><label for='choice_1_113_1' id='label_1_113_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_114' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Pulmonar \/ respiratorio.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_115' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Dificultad para respirar<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_115'><li class='gchoice_1_115_0'><input name='input_115' type='radio' value='Si'  id='choice_1_115_0' tabindex='131'    \/><label for='choice_1_115_0' id='label_1_115_0'>Si<\/label><\/li><li class='gchoice_1_115_1'><input name='input_115' type='radio' value='No'  id='choice_1_115_1' tabindex='132'    \/><label for='choice_1_115_1' id='label_1_115_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_116' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Ruidos respiratorios anormales<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_116'><li class='gchoice_1_116_0'><input name='input_116' type='radio' value='Si'  id='choice_1_116_0' tabindex='133'    \/><label for='choice_1_116_0' id='label_1_116_0'>Si<\/label><\/li><li class='gchoice_1_116_1'><input name='input_116' type='radio' value='No'  id='choice_1_116_1' tabindex='134'    \/><label for='choice_1_116_1' id='label_1_116_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_117' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Asma<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'><li class='gchoice_1_117_0'><input name='input_117' type='radio' value='Si'  id='choice_1_117_0' tabindex='135'    \/><label for='choice_1_117_0' id='label_1_117_0'>Si<\/label><\/li><li class='gchoice_1_117_1'><input name='input_117' type='radio' value='No'  id='choice_1_117_1' tabindex='136'    \/><label for='choice_1_117_1' id='label_1_117_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_118' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Enfermedades pulmonares previas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_118'><li class='gchoice_1_118_0'><input name='input_118' type='radio' value='Si'  id='choice_1_118_0' tabindex='137'    \/><label for='choice_1_118_0' id='label_1_118_0'>Si<\/label><\/li><li class='gchoice_1_118_1'><input name='input_118' type='radio' value='No'  id='choice_1_118_1' tabindex='138'    \/><label for='choice_1_118_1' id='label_1_118_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_119' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_119' >Otros<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_1_119' type='text' value='' class='medium'  tabindex='139'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_120' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_120' >Medicamentos<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_1_120' type='text' value='' class='medium'  tabindex='140'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_121' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Psicosocial.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_122' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Depresi\u00f3n<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_122'><li class='gchoice_1_122_0'><input name='input_122' type='radio' value='Si'  id='choice_1_122_0' tabindex='141'    \/><label for='choice_1_122_0' id='label_1_122_0'>Si<\/label><\/li><li class='gchoice_1_122_1'><input name='input_122' type='radio' value='No'  id='choice_1_122_1' tabindex='142'    \/><label for='choice_1_122_1' id='label_1_122_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_123' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Ansiedad<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_123'><li class='gchoice_1_123_0'><input name='input_123' type='radio' value='Si'  id='choice_1_123_0' tabindex='143'    \/><label for='choice_1_123_0' id='label_1_123_0'>Si<\/label><\/li><li class='gchoice_1_123_1'><input name='input_123' type='radio' value='No'  id='choice_1_123_1' tabindex='144'    \/><label for='choice_1_123_1' id='label_1_123_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_124' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Dificultad para dormir<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_124'><li class='gchoice_1_124_0'><input name='input_124' type='radio' value='Si'  id='choice_1_124_0' tabindex='145'    \/><label for='choice_1_124_0' id='label_1_124_0'>Si<\/label><\/li><li class='gchoice_1_124_1'><input name='input_124' type='radio' value='No'  id='choice_1_124_1' tabindex='146'    \/><label for='choice_1_124_1' id='label_1_124_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_125' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Bulimia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_125'><li class='gchoice_1_125_0'><input name='input_125' type='radio' value='Si'  id='choice_1_125_0' tabindex='147'    \/><label for='choice_1_125_0' id='label_1_125_0'>Si<\/label><\/li><li class='gchoice_1_125_1'><input name='input_125' type='radio' value='No'  id='choice_1_125_1' tabindex='148'    \/><label for='choice_1_125_1' id='label_1_125_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_126' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anorexia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_126'><li class='gchoice_1_126_0'><input name='input_126' type='radio' value='Si'  id='choice_1_126_0' tabindex='149'    \/><label for='choice_1_126_0' id='label_1_126_0'>Si<\/label><\/li><li class='gchoice_1_126_1'><input name='input_126' type='radio' value='No'  id='choice_1_126_1' tabindex='150'    \/><label for='choice_1_126_1' id='label_1_126_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_127' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Trastorno obsesivo compulsivo<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_127'><li class='gchoice_1_127_0'><input name='input_127' type='radio' value='Si'  id='choice_1_127_0' tabindex='151'    \/><label for='choice_1_127_0' id='label_1_127_0'>Si<\/label><\/li><li class='gchoice_1_127_1'><input name='input_127' type='radio' value='No'  id='choice_1_127_1' tabindex='152'    \/><label for='choice_1_127_1' id='label_1_127_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_128' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_128' >Otros<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_1_128' type='text' value='' class='medium'  tabindex='153'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_129' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_129' >Medicamentos<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_1_129' type='text' value='' class='medium'  tabindex='154'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_130' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Antecedentes familiares.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_131' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >C\u00e1ncer<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_131'><li class='gchoice_1_131_0'><input name='input_131' type='radio' value='Si'  id='choice_1_131_0' tabindex='155'    \/><label for='choice_1_131_0' id='label_1_131_0'>Si<\/label><\/li><li class='gchoice_1_131_1'><input name='input_131' type='radio' value='No'  id='choice_1_131_1' tabindex='156'    \/><label for='choice_1_131_1' id='label_1_131_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_132' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_132' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_1_132' type='text' value='' class='medium'  tabindex='157'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_133' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hipertensi\u00f3n arterial<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_133'><li class='gchoice_1_133_0'><input name='input_133' type='radio' value='Si'  id='choice_1_133_0' tabindex='158'    \/><label for='choice_1_133_0' id='label_1_133_0'>Si<\/label><\/li><li class='gchoice_1_133_1'><input name='input_133' type='radio' value='No'  id='choice_1_133_1' tabindex='159'    \/><label for='choice_1_133_1' id='label_1_133_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_134' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_134' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_1_134' type='text' value='' class='medium'  tabindex='160'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_135' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_135'><li class='gchoice_1_135_0'><input name='input_135' type='radio' value='Si'  id='choice_1_135_0' tabindex='161'    \/><label for='choice_1_135_0' id='label_1_135_0'>Si<\/label><\/li><li class='gchoice_1_135_1'><input name='input_135' type='radio' value='No'  id='choice_1_135_1' tabindex='162'    \/><label for='choice_1_135_1' id='label_1_135_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_136' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_136' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_1_136' type='text' value='' class='medium'  tabindex='163'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_137' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Triglic\u00e9ridos elevados en sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_137'><li class='gchoice_1_137_0'><input name='input_137' type='radio' value='Si'  id='choice_1_137_0' tabindex='164'    \/><label for='choice_1_137_0' id='label_1_137_0'>Si<\/label><\/li><li class='gchoice_1_137_1'><input name='input_137' type='radio' value='No'  id='choice_1_137_1' tabindex='165'    \/><label for='choice_1_137_1' id='label_1_137_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_138' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_138' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_1_138' type='text' value='' class='medium'  tabindex='166'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_142' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Colesterol elevado en sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_142'><li class='gchoice_1_142_0'><input name='input_142' type='radio' value='Si'  id='choice_1_142_0' tabindex='167'    \/><label for='choice_1_142_0' id='label_1_142_0'>Si<\/label><\/li><li class='gchoice_1_142_1'><input name='input_142' type='radio' value='No'  id='choice_1_142_1' tabindex='168'    \/><label for='choice_1_142_1' id='label_1_142_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_141' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_141' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_1_141' type='text' value='' class='medium'  tabindex='169'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_143' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Obesidad<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_143'><li class='gchoice_1_143_0'><input name='input_143' type='radio' value='Si'  id='choice_1_143_0' tabindex='170'    \/><label for='choice_1_143_0' id='label_1_143_0'>Si<\/label><\/li><li class='gchoice_1_143_1'><input name='input_143' type='radio' value='No'  id='choice_1_143_1' tabindex='171'    \/><label for='choice_1_143_1' id='label_1_143_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_140' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_140' >Por favor especificar parentesco<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_1_140' type='text' value='' class='medium'  tabindex='172'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_144' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Otros antecedentes m\u00e9dicos.<\/h3>\n<p>(Por favor, marque las casillas que apliquen en su caso)<\/p><\/li><li id='field_1_145' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hospitalizaciones<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_145'><li class='gchoice_1_145_0'><input name='input_145' type='radio' value='Si'  id='choice_1_145_0' tabindex='173'    \/><label for='choice_1_145_0' id='label_1_145_0'>Si<\/label><\/li><li class='gchoice_1_145_1'><input name='input_145' type='radio' value='No'  id='choice_1_145_1' tabindex='174'    \/><label for='choice_1_145_1' id='label_1_145_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_146' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Fracturas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'><li class='gchoice_1_146_0'><input name='input_146' type='radio' value='Si'  id='choice_1_146_0' tabindex='175'    \/><label for='choice_1_146_0' id='label_1_146_0'>Si<\/label><\/li><li class='gchoice_1_146_1'><input name='input_146' type='radio' value='No'  id='choice_1_146_1' tabindex='176'    \/><label for='choice_1_146_1' id='label_1_146_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_147' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cirug\u00edas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_147'><li class='gchoice_1_147_0'><input name='input_147' type='radio' value='Si'  id='choice_1_147_0' tabindex='177'    \/><label for='choice_1_147_0' id='label_1_147_0'>Si<\/label><\/li><li class='gchoice_1_147_1'><input name='input_147' type='radio' value='No'  id='choice_1_147_1' tabindex='178'    \/><label for='choice_1_147_1' id='label_1_147_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_148' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Transfusiones de sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_148'><li class='gchoice_1_148_0'><input name='input_148' type='radio' value='Si'  id='choice_1_148_0' tabindex='179'    \/><label for='choice_1_148_0' id='label_1_148_0'>Si<\/label><\/li><li class='gchoice_1_148_1'><input name='input_148' type='radio' value='No'  id='choice_1_148_1' tabindex='180'    \/><label for='choice_1_148_1' id='label_1_148_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_149' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Reacciones a transfusiones de sangre<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_149'><li class='gchoice_1_149_0'><input name='input_149' type='radio' value='Si'  id='choice_1_149_0' tabindex='181'    \/><label for='choice_1_149_0' id='label_1_149_0'>Si<\/label><\/li><li class='gchoice_1_149_1'><input name='input_149' type='radio' value='No'  id='choice_1_149_1' tabindex='182'    \/><label for='choice_1_149_1' id='label_1_149_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_150' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_150' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_1_150' type='text' value='' class='medium'  tabindex='183'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_151' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Enfermedad renal<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_151'><li class='gchoice_1_151_0'><input name='input_151' type='radio' value='Si'  id='choice_1_151_0' tabindex='184'    \/><label for='choice_1_151_0' id='label_1_151_0'>Si<\/label><\/li><li class='gchoice_1_151_1'><input name='input_151' type='radio' value='No'  id='choice_1_151_1' tabindex='185'    \/><label for='choice_1_151_1' id='label_1_151_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_152' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_152' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_1_152' type='text' value='' class='medium'  tabindex='186'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_153' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Enfermedad del h\u00edgado<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_153'><li class='gchoice_1_153_0'><input name='input_153' type='radio' value='Si'  id='choice_1_153_0' tabindex='187'    \/><label for='choice_1_153_0' id='label_1_153_0'>Si<\/label><\/li><li class='gchoice_1_153_1'><input name='input_153' type='radio' value='No'  id='choice_1_153_1' tabindex='188'    \/><label for='choice_1_153_1' id='label_1_153_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_154' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_154' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_1_154' type='text' value='' class='medium'  tabindex='189'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_158' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anemia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_158'><li class='gchoice_1_158_0'><input name='input_158' type='radio' value='Si'  id='choice_1_158_0' tabindex='190'    \/><label for='choice_1_158_0' id='label_1_158_0'>Si<\/label><\/li><li class='gchoice_1_158_1'><input name='input_158' type='radio' value='No'  id='choice_1_158_1' tabindex='191'    \/><label for='choice_1_158_1' id='label_1_158_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_156' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_156' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_1_156' type='text' value='' class='medium'  tabindex='192'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_155' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Di\u00e1lisis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_155'><li class='gchoice_1_155_0'><input name='input_155' type='radio' value='Si'  id='choice_1_155_0' tabindex='193'    \/><label for='choice_1_155_0' id='label_1_155_0'>Si<\/label><\/li><li class='gchoice_1_155_1'><input name='input_155' type='radio' value='No'  id='choice_1_155_1' tabindex='194'    \/><label for='choice_1_155_1' id='label_1_155_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_157' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_157' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_1_157' type='text' value='' class='medium'  tabindex='195'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_160' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Colostom\u00eda<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_160'><li class='gchoice_1_160_0'><input name='input_160' type='radio' value='Si'  id='choice_1_160_0' tabindex='196'    \/><label for='choice_1_160_0' id='label_1_160_0'>Si<\/label><\/li><li class='gchoice_1_160_1'><input name='input_160' type='radio' value='No'  id='choice_1_160_1' tabindex='197'    \/><label for='choice_1_160_1' id='label_1_160_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_159' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_159' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_1_159' type='text' value='' class='medium'  tabindex='198'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_162' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Impedimentos auditivos<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_162'><li class='gchoice_1_162_0'><input name='input_162' type='radio' value='Si'  id='choice_1_162_0' tabindex='199'    \/><label for='choice_1_162_0' id='label_1_162_0'>Si<\/label><\/li><li class='gchoice_1_162_1'><input name='input_162' type='radio' value='No'  id='choice_1_162_1' tabindex='200'    \/><label for='choice_1_162_1' id='label_1_162_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_161' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_161' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_1_161' type='text' value='' class='medium'  tabindex='201'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_164' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Impedimentos visuales<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_164'><li class='gchoice_1_164_0'><input name='input_164' type='radio' value='Si'  id='choice_1_164_0' tabindex='202'    \/><label for='choice_1_164_0' id='label_1_164_0'>Si<\/label><\/li><li class='gchoice_1_164_1'><input name='input_164' type='radio' value='No'  id='choice_1_164_1' tabindex='203'    \/><label for='choice_1_164_1' id='label_1_164_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_163' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_163' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_1_163' type='text' value='' class='medium'  tabindex='204'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_165' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Impedimentos de movilizaci\u00f3n<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_165'><li class='gchoice_1_165_0'><input name='input_165' type='radio' value='Si'  id='choice_1_165_0' tabindex='205'    \/><label for='choice_1_165_0' id='label_1_165_0'>Si<\/label><\/li><li class='gchoice_1_165_1'><input name='input_165' type='radio' value='No'  id='choice_1_165_1' tabindex='206'    \/><label for='choice_1_165_1' id='label_1_165_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_166' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_166' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_1_166' type='text' value='' class='medium'  tabindex='207'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_167' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Von Sillebrand<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_167'><li class='gchoice_1_167_0'><input name='input_167' type='radio' value='Si'  id='choice_1_167_0' tabindex='208'    \/><label for='choice_1_167_0' id='label_1_167_0'>Si<\/label><\/li><li class='gchoice_1_167_1'><input name='input_167' type='radio' value='No'  id='choice_1_167_1' tabindex='209'    \/><label for='choice_1_167_1' id='label_1_167_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_169' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_169' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_1_169' type='text' value='' class='medium'  tabindex='210'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_170' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Amputaciones<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_170'><li class='gchoice_1_170_0'><input name='input_170' type='radio' value='Si'  id='choice_1_170_0' tabindex='211'    \/><label for='choice_1_170_0' id='label_1_170_0'>Si<\/label><\/li><li class='gchoice_1_170_1'><input name='input_170' type='radio' value='No'  id='choice_1_170_1' tabindex='212'    \/><label for='choice_1_170_1' id='label_1_170_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_168' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_168' >En caso de que aplique favor de especificar<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_1_168' type='text' value='' class='medium'  tabindex='213'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_171' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_171' >Otros<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_1_171' type='text' value='' class='medium'  tabindex='214'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_172' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_172' >Medicamentos no mencionados antes<\/label><div class='ginput_container ginput_container_text'><input name='input_172' 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