{"id":3420,"date":"2024-04-02T17:47:56","date_gmt":"2024-04-02T17:47:56","guid":{"rendered":"https:\/\/new.drmartinrobles.com\/?page_id=3420"},"modified":"2024-04-05T19:20:56","modified_gmt":"2024-04-05T19:20:56","slug":"form","status":"publish","type":"page","link":"https:\/\/drmartinrobles.com\/en\/form\/","title":{"rendered":"Evaluation Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3420\" class=\"elementor elementor-3420\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-cb1e49b elementor-section-height-min-height cs-section-content-fullwidth cs-parallax-on-scroll cs_scroll_y_100 elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"cb1e49b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\" data-cs-parallax-y=\"100\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3942523 dark-color\" data-id=\"3942523\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7d85662 elementor-widget elementor-widget-text-editor\" data-id=\"7d85662\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<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' target='gform_ajax_frame_4' id='gform_4'  action='\/en\/wp-json\/wp\/v2\/pages\/3420#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_4_16\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds capitalize gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nombre<\/span><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 no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_16'>\n                            \n                            <span id='input_4_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_4_16_3' value=''   aria-required='true'   placeholder='Nombre(s) *'  \/>\n                                                    <label for='input_4_16_3' class='gform-field-label gform-field-label--type-sub '>Nombre(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_4_16_6' value=''   aria-required='true'   placeholder='Apellido(s) *'  \/>\n                                                    <label for='input_4_16_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sexo<\/span><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_66'>\n\t\t\t<li class='gchoice gchoice_4_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Femenino' checked='checked' id='choice_4_66_0'    \/>\n\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0' class='gform-field-label gform-field-label--type-inline'>Femenino<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Masculino'  id='choice_4_66_1'    \/>\n\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1' class='gform-field-label gform-field-label--type-inline'>Masculino<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_67\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de nacimiento<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_67' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_67_2_container'><label for='input_4_67_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_67[]' id='input_4_67_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_67_1_container'><label for='input_4_67_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_67[]' id='input_4_67_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_67_3_container'><label for='input_4_67_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_67[]' id='input_4_67_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfUsted es paciente local o internacional?<\/span><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_147'>\n\t\t\t<li class='gchoice gchoice_4_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Consulta Virtual (s\u00f3lo si resides en el extranjero)' checked='checked' 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'>Consulta Virtual (s\u00f3lo si resides en el extranjero)<\/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='Consulta Presencial (en consultorio)'  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'>Consulta Presencial (en consultorio)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_110'><span class='gform-field-label__text'>Nacionalidad<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_4_110' type='text' value='' class='large'    placeholder='Nacionalidad *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_4_17' type='email' value='' class='large'   placeholder='Email *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_68\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_68'><span class='gform-field-label__text'>M\u00f3vil<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_68' id='input_4_68' type='tel' value='' class='large'  placeholder='M\u00f3vil *' aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_4_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_right_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_107'><span class='gform-field-label__text'>C\u00e9dula \/ Pasaporte<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_4_107' type='text' value='' class='large'    placeholder='C\u00e9dula \/ Pasaporte *'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Direcci\u00f3n<\/span><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_country ginput_container_address gform-grid-row' id='input_4_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_4_23_1' value=''   placeholder='Calle \/ Avenida \/ No.*' aria-required='true'    \/>\n                                        <label for='input_4_23_1' id='input_4_23_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_4_23_3' value=''   placeholder='Ciudad *' aria-required='true'    \/>\n                                    <label for='input_4_23_3' id='input_4_23_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_23_4_container' >\n                                        <input type='text' name='input_23.4' id='input_4_23_4' value=''     placeholder='Estado\/Provincia *' aria-required='true'    \/>\n                                        <label for='input_4_23_4' id='input_4_23_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_4_23_6_container' >\n                                        <select name='input_23.6' id='input_4_23_6'   aria-required='true'    ><option value='' >Pa\u00eds *<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_4_23_6' id='input_4_23_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_120'><span class='gform-field-label__text'>Profesi\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_4_120' type='text' value='' class='large'    placeholder='Profesi\u00f3n *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_middle_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_70'><span class='gform-field-label__text'>Instagram user:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_4_70' type='text' value='' class='large'    placeholder='Instagram'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_right_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'><span class='gform-field-label__text'>Recomendada por<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='large'    placeholder='Recomendado por'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_151'><span class='gform-field-label__text'>Edad<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_4_151' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_167\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_132\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_132'><span class='gform-field-label__text'>Peso Actual (lbs)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_132' id='input_4_132' type='number' step='any' min='80' max='300' value='' class='large'    placeholder='Peso Actual (lbs) *' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_4_132\" \/><div class='gfield_description instruction ' id='gfield_instruction_4_132'>Please enter a number from <strong>80<\/strong> to <strong>300<\/strong>.<\/div><\/div><\/li><li id=\"field_4_131\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_131'><span class='gform-field-label__text'>Estatura (pie,pulg.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_131' id='input_4_131' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Estatura *<\/option><option value='60' >5 feet<\/option><option value='61' >5\u20191<\/option><option value='62' >5\u20192<\/option><option value='63' >5\u20193<\/option><option value='64' >5\u20194<\/option><option value='65' >5\u20195<\/option><option value='66' >5\u20196<\/option><option value='67' >5\u20197<\/option><option value='68' >5\u20198<\/option><option value='69' >5\u20199<\/option><option value='70' >5\u201910<\/option><option value='71' >5\u201911<\/option><option value='72' >6 feet<\/option><option value='73' >6&#039;1<\/option><option value='74' >6&#039;2<\/option><option value='75' >6&#039;3<\/option><option value='76' >6&#039;4<\/option><option value='77' >6&#039;5<\/option><\/select><\/div><\/li><li id=\"field_4_152\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_152'><span class='gform-field-label__text'>Tipo de Sangre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_4_152' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Tipo de Sangre<\/option><option value='A+' >A+<\/option><option value='A-' >A-<\/option><option value='AB-' >AB-<\/option><option value='AB+' >AB+<\/option><option value='B+' >B+<\/option><option value='B-' >B-<\/option><option value='O-' >O-<\/option><option value='O+' >O+<\/option><option value='No s\u00e9' >No s\u00e9<\/option><\/select><\/div><\/li><li id=\"field_4_143\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gf_left_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_143'><span class='gform-field-label__text'>Estatura Pulg<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_143' id='input_4_143' type='text' step='any' min='80' max='300' value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_133\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_133'><span class='gform-field-label__text'>BMI<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_133' id='input_4_133' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='IMC'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_144\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_left_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_144'><span class='gform-field-label__text'>Peso Actual (kgs)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_144' id='input_4_144' type='text' step='any' min='80' max='300' value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_142\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_142'><span class='gform-field-label__text'>Estatura (cm.)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_142' id='input_4_142' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='Estatura (cm.)'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfSufre o ha sufrido de alguna enfermedades o condiciones de salud?<\/span><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_153'>\n\t\t\t<li class='gchoice gchoice_4_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='S\u00ed'  id='choice_4_153_0'    \/>\n\t\t\t\t<label for='choice_4_153_0' id='label_4_153_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_4_153_1'    \/>\n\t\t\t\t<label for='choice_4_153_1' id='label_4_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Favor especifique cu\u00e1les enfermedades<\/span><\/label><div class='gfield_description' id='gfield_description_4_51'>Seleccione todas las que apliquen<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_51'><li class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Arritmias'  id='choice_4_51_1'   aria-describedby=\"gfield_description_4_51\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>Arritmias<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Asma'  id='choice_4_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' 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_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Asma Bronquial'  id='choice_4_51_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>Asma Bronquial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='Colesterol Elevado'  id='choice_4_51_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>Colesterol Elevado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='Constipaci\u00f3n (estre\u00f1imiento)'  id='choice_4_51_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>Constipaci\u00f3n (estre\u00f1imiento)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='Depresi\u00f3n'  id='choice_4_51_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' 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_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='Diabetes'  id='choice_4_51_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_7' id='label_4_51_7' 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_51_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.8' type='checkbox'  value='Enfermedad Psiqui\u00e1trica'  id='choice_4_51_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_8' id='label_4_51_8' class='gform-field-label gform-field-label--type-inline'>Enfermedad Psiqui\u00e1trica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.9' type='checkbox'  value='Enfermedades del Coraz\u00f3n'  id='choice_4_51_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_9' id='label_4_51_9' class='gform-field-label gform-field-label--type-inline'>Enfermedades del Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.11' type='checkbox'  value='HIV (Sida)'  id='choice_4_51_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_11' id='label_4_51_11' class='gform-field-label gform-field-label--type-inline'>HIV (Sida)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.12' type='checkbox'  value='Hepatitis'  id='choice_4_51_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_12' id='label_4_51_12' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.13' type='checkbox'  value='Hipertensi\u00f3n Arterial'  id='choice_4_51_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_13' id='label_4_51_13' class='gform-field-label gform-field-label--type-inline'>Hipertensi\u00f3n Arterial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.14' type='checkbox'  value='Historia de anemia'  id='choice_4_51_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_14' id='label_4_51_14' class='gform-field-label gform-field-label--type-inline'>Historia de anemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.15' type='checkbox'  value='Infartos'  id='choice_4_51_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_15' id='label_4_51_15' class='gform-field-label gform-field-label--type-inline'>Infartos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.16' type='checkbox'  value='Presi\u00f3n arterial'  id='choice_4_51_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_16' id='label_4_51_16' class='gform-field-label gform-field-label--type-inline'>Presi\u00f3n arterial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.17' type='checkbox'  value='Sangrado'  id='choice_4_51_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_17' id='label_4_51_17' class='gform-field-label gform-field-label--type-inline'>Sangrado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.18' type='checkbox'  value='Tiroides'  id='choice_4_51_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_18' id='label_4_51_18' class='gform-field-label gform-field-label--type-inline'>Tiroides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.19' type='checkbox'  value='Tromboflebitis'  id='choice_4_51_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_19' id='label_4_51_19' class='gform-field-label gform-field-label--type-inline'>Tromboflebitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.21' type='checkbox'  value='Trombosis venosa'  id='choice_4_51_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_21' id='label_4_51_21' class='gform-field-label gform-field-label--type-inline'>Trombosis venosa<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.22' type='checkbox'  value='Varices'  id='choice_4_51_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_22' id='label_4_51_22' class='gform-field-label gform-field-label--type-inline'>Varices<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.23' type='checkbox'  value='Otras'  id='choice_4_51_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_23' id='label_4_51_23' class='gform-field-label gform-field-label--type-inline'>Otras<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_83'><span class='gform-field-label__text'>Favor especifique su condici\u00f3n psiqui\u00e1trica<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_4_83' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_52'><span class='gform-field-label__text'>Favor especifique su problema de salud<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTiene antecedentes familiares de alguna enfermedad o condici\u00f3n de salud?<\/span><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_154'>\n\t\t\t<li class='gchoice gchoice_4_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='S\u00ed'  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'>S\u00ed<\/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='No'  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'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_79'><span class='gform-field-label__text'>Antecedentes Familiares: Indique si padece o ha padecido enfermedades de familiares cercanos (padre, madre, hermanos e hijos)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_4_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma alg\u00fan medicamento o suplemento regularmente?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_45'>(para la presi\u00f3n, antidepresivos, prote\u00edna, suplementos para p\u00e9rdida de peso, vitaminas)<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_45'>\n\t\t\t<li class='gchoice gchoice_4_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='S\u00ed'  id='choice_4_45_0'    \/>\n\t\t\t\t<label for='choice_4_45_0' id='label_4_45_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_4_45_1'    \/>\n\t\t\t\t<label for='choice_4_45_1' id='label_4_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_33'><span class='gform-field-label__text'>Especifique los medicamentos \/ suplementos que toma<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfUsted o alg\u00fan familiar es portador o padece FALCEMIA?<\/span><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_128'>\n\t\t\t<li class='gchoice gchoice_4_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='S\u00ed'  id='choice_4_128_0'    \/>\n\t\t\t\t<label for='choice_4_128_0' id='label_4_128_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_4_128_1'    \/>\n\t\t\t\t<label for='choice_4_128_1' id='label_4_128_1' 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_128_2'>\n\t\t\t\t<input name='input_128' type='radio' value='Familiar'  id='choice_4_128_2'    \/>\n\t\t\t\t<label for='choice_4_128_2' id='label_4_128_2' class='gform-field-label gform-field-label--type-inline'>Familiar<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_129\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_129'><span class='gform-field-label__text'>Favor especifique sobre su condici\u00f3n de falcemia o la de su familiar<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_4_129' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_168\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>\u00bfSe ha realizado alguna cirug\u00eda anterior? Seleccione la que aplique.<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_74'><li class='gchoice gchoice_4_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Cirug\u00eda General (bari\u00e1trica, apendicectom\u00eda, extracci\u00f3n de ves\u00edcula,etc.)'  id='choice_4_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>Cirug\u00eda General (bari\u00e1trica, apendicectom\u00eda, extracci\u00f3n de ves\u00edcula,etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Cirug\u00edas Est\u00e9ticas anteriores (reducci\u00f3n de mamas, liposucci\u00f3n, etc.)'  id='choice_4_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_74_2' id='label_4_74_2' class='gform-field-label gform-field-label--type-inline'>Cirug\u00edas Est\u00e9ticas anteriores (reducci\u00f3n de mamas, liposucci\u00f3n, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_176\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-seven-twelfths gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfSe ha sometido a alguna cirug\u00eda est\u00e9tica o general anteriormente?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_176'>Ejemplo: liposucci\u00f3n, ces\u00e1rea, barb\u00e1rica, etc.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_176'>\n\t\t\t<li class='gchoice gchoice_4_176_0'>\n\t\t\t\t<input name='input_176' type='radio' value='S\u00ed'  id='choice_4_176_0'    \/>\n\t\t\t\t<label for='choice_4_176_0' id='label_4_176_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_176_1'>\n\t\t\t\t<input name='input_176' type='radio' value='No'  id='choice_4_176_1'    \/>\n\t\t\t\t<label for='choice_4_176_1' id='label_4_176_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_177\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_177'><span class='gform-field-label__text'>\u00bfCu\u00e1ntas cirug\u00edas ha tenido antes?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_177' id='input_4_177' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_4_178\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Por favor, describe el tipo de cirug\u00eda, la fecha y si hubo complicaciones en cada una.<\/h3><\/li><li id=\"field_4_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'><span class='gform-field-label__text'>1era Cirug\u00eda (tipo)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_4_87' type='text' value='' class='large'    placeholder='Ejemplo: Liposucci\u00f3n, bbl, ces\u00e1rea, bari\u00e1trica....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_174\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de 1era Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_174' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_174_2_container'><label for='input_4_174_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_174[]' id='input_4_174_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_174_1_container'><label for='input_4_174_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_174[]' id='input_4_174_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_174_3_container'><label for='input_4_174_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_174[]' id='input_4_174_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_180\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo complicaciones en la 1era cirug\u00eda?<\/span><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_180'>\n\t\t\t<li class='gchoice gchoice_4_180_0'>\n\t\t\t\t<input name='input_180' type='radio' value='S\u00ed'  id='choice_4_180_0'    \/>\n\t\t\t\t<label for='choice_4_180_0' id='label_4_180_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_180_1'>\n\t\t\t\t<input name='input_180' type='radio' value='No'  id='choice_4_180_1'    \/>\n\t\t\t\t<label for='choice_4_180_1' id='label_4_180_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_184\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_184'><span class='gform-field-label__text'>Especifique las complicaciones de la 1era Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_4_184' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_179\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_179'><span class='gform-field-label__text'>2da Cirug\u00eda (tipo)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_4_179' type='text' value='' class='large'    placeholder='Ejemplo: Liposucci\u00f3n, bbl, ces\u00e1rea, bari\u00e1trica....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_183\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de 2da Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_183' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_183_2_container'><label for='input_4_183_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_183[]' id='input_4_183_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_183_1_container'><label for='input_4_183_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_183[]' id='input_4_183_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_183_3_container'><label for='input_4_183_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_183[]' id='input_4_183_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo complicaciones en la 2da cirug\u00eda?<\/span><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_182'>\n\t\t\t<li class='gchoice gchoice_4_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='S\u00ed'  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'>S\u00ed<\/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='No'  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'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_181\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_181'><span class='gform-field-label__text'>Especifique las complicaciones de la 2da Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_4_181' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_185\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_185'><span class='gform-field-label__text'>3era Cirug\u00eda (tipo)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_4_185' type='text' value='' class='large'    placeholder='Ejemplo: Liposucci\u00f3n, bbl, ces\u00e1rea, bari\u00e1trica....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_186\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de 3era Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_186' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_186_2_container'><label for='input_4_186_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_186[]' id='input_4_186_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_186_1_container'><label for='input_4_186_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_186[]' id='input_4_186_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_186_3_container'><label for='input_4_186_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_186[]' id='input_4_186_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo complicaciones en la 3era cirug\u00eda?<\/span><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_187'>\n\t\t\t<li class='gchoice gchoice_4_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='S\u00ed'  id='choice_4_187_0'    \/>\n\t\t\t\t<label for='choice_4_187_0' id='label_4_187_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_4_187_1'    \/>\n\t\t\t\t<label for='choice_4_187_1' id='label_4_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_188\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_188'><span class='gform-field-label__text'>Especifique las complicaciones de la 3era Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_4_188' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_190\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_190'><span class='gform-field-label__text'>4ta Cirug\u00eda (tipo)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_4_190' type='text' value='' class='large'    placeholder='Ejemplo: Liposucci\u00f3n, bbl, ces\u00e1rea, bari\u00e1trica....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_191\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de 4ta Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_191' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_191_2_container'><label for='input_4_191_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_191[]' id='input_4_191_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_191_1_container'><label for='input_4_191_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_191[]' id='input_4_191_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_191_3_container'><label for='input_4_191_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_191[]' id='input_4_191_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo complicaciones en la 4ta cirug\u00eda?<\/span><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_192'>\n\t\t\t<li class='gchoice gchoice_4_192_0'>\n\t\t\t\t<input name='input_192' type='radio' value='S\u00ed'  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'>S\u00ed<\/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='No'  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'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_189\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_189'><span class='gform-field-label__text'>Especifique las complicaciones de la 4ta Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_4_189' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_194\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_194'><span class='gform-field-label__text'>5ta Cirug\u00eda (tipo)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_4_194' type='text' value='' class='large'    placeholder='Ejemplo: Liposucci\u00f3n, bbl, ces\u00e1rea, bari\u00e1trica....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_195\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de 5ta Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_195' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_195_2_container'><label for='input_4_195_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_195[]' id='input_4_195_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_195_1_container'><label for='input_4_195_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_195[]' id='input_4_195_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_195_3_container'><label for='input_4_195_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Anno<\/label><select name='input_195[]' id='input_4_195_3'   aria-required='true'  ><option value=''>Anno<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo complicaciones en la 5ta cirug\u00eda?<\/span><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_196'>\n\t\t\t<li class='gchoice gchoice_4_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='S\u00ed'  id='choice_4_196_0'    \/>\n\t\t\t\t<label for='choice_4_196_0' id='label_4_196_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='No'  id='choice_4_196_1'    \/>\n\t\t\t\t<label for='choice_4_196_1' id='label_4_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_193\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_193'><span class='gform-field-label__text'>Especifique las complicaciones de la 5ta Cirug\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo alguna complicaci\u00f3n en dicha cirug\u00eda est\u00e9tica?<\/span><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_163'>\n\t\t\t<li class='gchoice gchoice_4_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='S\u00ed'  id='choice_4_163_0'    \/>\n\t\t\t\t<label for='choice_4_163_0' id='label_4_163_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='No'  id='choice_4_163_1'    \/>\n\t\t\t\t<label for='choice_4_163_1' id='label_4_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_161'><span class='gform-field-label__text'>Especificque sobre la complicaci\u00f3n que tuvo en su cirug\u00eda est\u00e9tica anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_4_161' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_93'><span class='gform-field-label__text'>Cirug\u00eda General anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_93'>Favor especifique el tipo de cirug\u00eda(s) realizada<\/div><div class='ginput_container ginput_container_text'><input name='input_93' id='input_4_93' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_93\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_175\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_175'><span class='gform-field-label__text'>Fecha de cirug\u00eda general anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_4_175'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_175'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_4_175' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_4_175' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_4_175' aria-label='Fecha de cirug\u00eda general anterior: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_4_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTuvo alguna complicaci\u00f3n en dicha cirug\u00eda general?<\/span><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_164'>\n\t\t\t<li class='gchoice gchoice_4_164_0'>\n\t\t\t\t<input name='input_164' type='radio' value='S\u00ed'  id='choice_4_164_0'    \/>\n\t\t\t\t<label for='choice_4_164_0' id='label_4_164_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_164_1'>\n\t\t\t\t<input name='input_164' type='radio' value='No'  id='choice_4_164_1'    \/>\n\t\t\t\t<label for='choice_4_164_1' id='label_4_164_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_162'><span class='gform-field-label__text'>Especificque sobre la complicaci\u00f3n que tuvo en su cirug\u00eda general anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_4_162' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_169\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_119\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_119'><span class='gform-field-label__text'>\u00bfCu\u00e1ntos embarazos ha tenido?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_4_119' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Ninguno' >Ninguno<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/li><li id=\"field_4_130\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_130'><span class='gform-field-label__text'>\u00bfCu\u00e1ntos hijos ha tenido?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_4_130' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Ninguno' >Ninguno<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/li><li id=\"field_4_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_50'><span class='gform-field-label__text'>\u00bfC\u00f3mo fue su parto?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_4_50' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Parto Natural' >Parto Natural<\/option><option value='Ces\u00e1rea' >Ces\u00e1rea<\/option><option value='He tenido ambos' >He tenido ambos<\/option><\/select><\/div><\/li><li id=\"field_4_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Fecha de su \u00faltimo parto<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_73' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_73_2_container'><label for='input_4_73_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_73[]' id='input_4_73_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_73_1_container'><label for='input_4_73_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_73[]' id='input_4_73_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_73_3_container'><label for='input_4_73_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_73[]' id='input_4_73_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma anticonceptivos?<\/span><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_72'>\n\t\t\t<li class='gchoice gchoice_4_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='S\u00ed'  id='choice_4_72_0'    \/>\n\t\t\t\t<label for='choice_4_72_0' id='label_4_72_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_4_72_1'    \/>\n\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_127\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_127'><span class='gform-field-label__text'>Tipo de anticonceptivo<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_4_127' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='V\u00eda oral' >V\u00eda oral<\/option><option value='DIU' >DIU<\/option><\/select><\/div><\/li><li id=\"field_4_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEres al\u00e9rgico alg\u00fan medicamento?<\/span><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_36'>\n\t\t\t<li class='gchoice gchoice_4_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='S\u00ed'  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'>S\u00ed<\/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='No'  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'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'><span class='gform-field-label__text'>\u00bfA cu\u00e1l(es) medicamentos eres al\u00e9rgico?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfUsted fuma? O fum\u00f3 anteriormente?<\/span><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_53'>\n\t\t\t<li class='gchoice gchoice_4_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='S\u00ed'  id='choice_4_53_0'    \/>\n\t\t\t\t<label for='choice_4_53_0' id='label_4_53_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_4_53_1'    \/>\n\t\t\t\t<label for='choice_4_53_1' id='label_4_53_1' 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_53_2'>\n\t\t\t\t<input name='input_53' type='radio' value='Fumaba'  id='choice_4_53_2'    \/>\n\t\t\t\t<label for='choice_4_53_2' id='label_4_53_2' class='gform-field-label gform-field-label--type-inline'>Fumaba<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_156\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>\u00bfQu\u00e9 fuma o fumaba? Ej: cigarrillo, vape, etc&#8230;<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_156'><li class='gchoice gchoice_4_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Cigarrillos'  id='choice_4_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_1' id='label_4_156_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_156_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.2' type='checkbox'  value='Hooka'  id='choice_4_156_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_2' id='label_4_156_2' class='gform-field-label gform-field-label--type-inline'>Hooka<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.3' type='checkbox'  value='Vape \/ Cigarrillo Electr\u00f3nico'  id='choice_4_156_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_3' id='label_4_156_3' class='gform-field-label gform-field-label--type-inline'>Vape \/ Cigarrillo Electr\u00f3nico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.4' type='checkbox'  value='Cigarro \/ Tabaco'  id='choice_4_156_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_4' id='label_4_156_4' class='gform-field-label gform-field-label--type-inline'>Cigarro \/ Tabaco<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.5' type='checkbox'  value='Marihuana'  id='choice_4_156_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_5' id='label_4_156_5' class='gform-field-label gform-field-label--type-inline'>Marihuana<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_155'><span class='gform-field-label__text'>\u00bfCon qu\u00e9 frecuencia fuma o fumaba y cu\u00e1ntos a\u00f1os tiene\/ten\u00eda fumando?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_4_155' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma alcohol?<\/span><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_81'>\n\t\t\t<li class='gchoice gchoice_4_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='S\u00ed'  id='choice_4_81_0'    \/>\n\t\t\t\t<label for='choice_4_81_0' id='label_4_81_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_4_81_1'    \/>\n\t\t\t\t<label for='choice_4_81_1' id='label_4_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_82'><span class='gform-field-label__text'>\u00bfCon qu\u00e9 frecuencia toma alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_4_82' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHas tenido COVID?<\/span><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_134'>\n\t\t\t<li class='gchoice gchoice_4_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='S\u00ed'  id='choice_4_134_0'    \/>\n\t\t\t\t<label for='choice_4_134_0' id='label_4_134_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_4_134_1'    \/>\n\t\t\t\t<label for='choice_4_134_1' id='label_4_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_170\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>\u00bfQu\u00e9 procedimientos deseas realizarte?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_123'>Para ver una descripci\u00f3n de cada procedimiento, <a href=\"https:\/\/drmartinrobles.com\/procedimientos\/\" target=\"_blank\">ingresa aqu\u00ed<\/a>.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_123'><li class='gchoice gchoice_4_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Abdominoplast\u00eda'  id='choice_4_123_1'   aria-describedby=\"gfield_description_4_123\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_1' id='label_4_123_1' class='gform-field-label gform-field-label--type-inline'>Abdominoplast\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='BBL - Injerto de Grasa en Gl\u00fateos'  id='choice_4_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_2' id='label_4_123_2' class='gform-field-label gform-field-label--type-inline'>BBL &#8211; Injerto de Grasa en Gl\u00fateos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Braquioplast\u00eda'  id='choice_4_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_3' id='label_4_123_3' class='gform-field-label gform-field-label--type-inline'>Braquioplast\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.4' type='checkbox'  value='Cruroplast\u00eda'  id='choice_4_123_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_4' id='label_4_123_4' class='gform-field-label gform-field-label--type-inline'>Cruroplast\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.5' type='checkbox'  value='Injerto de Grasa a Mamas'  id='choice_4_123_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_5' id='label_4_123_5' class='gform-field-label gform-field-label--type-inline'>Injerto de Grasa a Mamas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.6' type='checkbox'  value='J-Plasma'  id='choice_4_123_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_6' id='label_4_123_6' class='gform-field-label gform-field-label--type-inline'>J-Plasma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.7' type='checkbox'  value='Lifting Facial'  id='choice_4_123_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_7' id='label_4_123_7' class='gform-field-label gform-field-label--type-inline'>Lifting Facial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.8' type='checkbox'  value='Lipo Papada'  id='choice_4_123_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_8' id='label_4_123_8' class='gform-field-label gform-field-label--type-inline'>Lipo Papada<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.9' type='checkbox'  value='Lipo Vaser'  id='choice_4_123_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_9' id='label_4_123_9' class='gform-field-label gform-field-label--type-inline'>Lipo Vaser<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.11' type='checkbox'  value='Lipo de Brazos'  id='choice_4_123_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_11' id='label_4_123_11' class='gform-field-label gform-field-label--type-inline'>Lipo de Brazos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.12' type='checkbox'  value='Lipoescultura'  id='choice_4_123_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_12' id='label_4_123_12' class='gform-field-label gform-field-label--type-inline'>Lipoescultura<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.13' type='checkbox'  value='Mamoplast\u00eda de Aumento'  id='choice_4_123_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_13' id='label_4_123_13' class='gform-field-label gform-field-label--type-inline'>Mamoplast\u00eda de Aumento<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.14' type='checkbox'  value='Marcaci\u00f3n Abdominal'  id='choice_4_123_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_14' id='label_4_123_14' class='gform-field-label gform-field-label--type-inline'>Marcaci\u00f3n Abdominal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.15' type='checkbox'  value='Mastopexia con Implantes'  id='choice_4_123_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_15' id='label_4_123_15' class='gform-field-label gform-field-label--type-inline'>Mastopexia con Implantes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.16' type='checkbox'  value='Mini Abdominoplast\u00eda'  id='choice_4_123_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_16' id='label_4_123_16' class='gform-field-label gform-field-label--type-inline'>Mini Abdominoplast\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.17' type='checkbox'  value='Reducci\u00f3n Mamaria'  id='choice_4_123_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_17' id='label_4_123_17' class='gform-field-label gform-field-label--type-inline'>Reducci\u00f3n Mamaria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.18' type='checkbox'  value='Otros'  id='choice_4_123_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_18' id='label_4_123_18' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_125'><span class='gform-field-label__text'>Otro procedimiento de inter\u00e9s<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_4_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_171\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_150\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><span style=\"color: #ffffff; font-size:22px;line-height:28px;font-weight:400;\">Favor enviarnos 5 fotos en las siguientes posiciones: frontal parada, de lado parada, de espalda parada, sentada de frente, sentada de lado y de rostro si aplica para su procedimiento.<br \/><br \/>\nNota: Sin ropa interior o ropa interior peque\u00f1a. Sin mostrar su rostro.<\/span>\n<\/li><li id=\"field_4_112\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_left_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_112'><span class='gform-field-label__text'>Foto Frontal<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_112' id='input_4_112' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_112\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_112'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_112'><\/div> <\/div><\/li><li id=\"field_4_115\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_middle_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_115'><span class='gform-field-label__text'>Foto Lateral<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_115' id='input_4_115' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_115\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_115'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_115'><\/div> <\/div><\/li><li id=\"field_4_114\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_right_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_114'><span class='gform-field-label__text'>Foto de Espalda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_114' id='input_4_114' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_114\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_114'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_114'><\/div> <\/div><\/li><li id=\"field_4_113\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_left_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_113'><span class='gform-field-label__text'>Foto Sentada de Frente<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_113' id='input_4_113' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_113\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_113'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_113'><\/div> <\/div><\/li><li id=\"field_4_117\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_middle_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_117'><span class='gform-field-label__text'>Foto Sentada de Lado<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_117' id='input_4_117' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_117\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_117'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_117'><\/div> <\/div><\/li><li id=\"field_4_116\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_right_third file_upload field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_116'><span class='gform-field-label__text'>Foto Adicional<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_116' id='input_4_116' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_116\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_116'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_116'><\/div> <\/div><\/li><li id=\"field_4_172\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_145\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_145'><span class='gform-field-label__text'>\u00bfPara cu\u00e1ndo planeas realizarse esta cirug\u00eda?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_145' id='input_4_145' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Inmediatamente' >Inmediatamente<\/option><option value='Lo antes posible' >Lo antes posible<\/option><option value='Pr\u00f3ximos meses' >Pr\u00f3ximos meses<\/option><option value='Este a\u00f1o' >Este a\u00f1o<\/option><option value='El a\u00f1o entrante' >El a\u00f1o entrante<\/option><option value='Depende' >Depende<\/option><\/select><\/div><\/li><li id=\"field_4_160\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_160'><span class='gform-field-label__text'>Idioma de Preferencia<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_160' id='input_4_160' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Espa\u00f1ol' >Espa\u00f1ol<\/option><option value='Ingl\u00e9s' >Ingl\u00e9s<\/option><\/select><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'><span class='gform-field-label__text'>Comentario:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_4_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_105\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_105'><span class='gform-field-label__text'>Lead Source<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_105' id='input_4_105' class='medium gfield_select'     aria-invalid=\"false\" ><option value='P\u00e1gina Web' selected='selected'>P\u00e1gina Web<\/option><\/select><\/div><\/li><li id=\"field_4_101\" class=\"gfield gfield--type-section gfield--input-type-section gsection pdf_no_display field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h2 class=\"gsection_title\">Consentimiento<\/h2><div class='gsection_description' id='gfield_description_4_101'><h4>Lea detenidamente los t\u00e9rminos<\/h4>\n<p style=\"font-size:12px; line-height:22px;\">Yo, {Nombre (Nombre):16.3} {Nombre (Apellidos):16.6}, portador (a) de la c\u00e9dula de identidad y electoral y\/o pasaporte No. {N\u00famero de C\u00e9dula:107}{N\u00famero de Pasaporte:108}, de nacionalidad {Nacionalidad:110}, en el d\u00eda {date_dmy}. DECLARO BAJO LA FE JURAMENTO, soy la (el) \u00fanica (\u00fanico)\u00a0 responsable ante todo da\u00f1o que me acaree cualquier omisi\u00f3n a la mala informaci\u00f3n\u00a0 que haya vertido en este documento despu\u00e9s de haber le\u00eddo detenidamente las preguntas realizadas por el Doctor Martin Robles, y comprendo que ocultar cualquier tipo de informaci\u00f3n m\u00e9dica a este o su personal m\u00e9dico, podr\u00eda poner en riesgo mi vida y salud, as\u00ed como la obligaci\u00f3n que tengo de notificar cualquier cambio o alternaci\u00f3n sobre las informaciones aqu\u00ed provistas.\n<br \/><br \/>\nFirma del paciente<br \/><br \/><br \/>\n\n\n ______________________________<br \/>\n {Nombre (Nombre):16.3} {Nombre (Apellidos):16.6}<\/p><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' 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