{"id":711,"date":"2024-05-31T19:48:26","date_gmt":"2024-05-31T19:48:26","guid":{"rendered":"https:\/\/ciba-usa.com\/?page_id=711"},"modified":"2024-05-31T19:49:02","modified_gmt":"2024-05-31T19:49:02","slug":"health-questionnaire","status":"publish","type":"page","link":"https:\/\/ciba-usa.com\/es\/health-questionnaire\/","title":{"rendered":"Cuestionario de Salud"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"711\" class=\"elementor elementor-711\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7f60fba e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"7f60fba\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4e7a3d5 elementor-widget elementor-widget-template\" data-id=\"4e7a3d5\" data-element_type=\"widget\" data-widget_type=\"template.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-template\">\n\t\t\t\t\t<div data-elementor-type=\"page\" data-elementor-id=\"708\" class=\"elementor elementor-708\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-71db9669 elementor-section-full_width elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"71db9669\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-46a47e84\" data-id=\"46a47e84\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-a1a265e elementor-widget elementor-widget-spacer\" data-id=\"a1a265e\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-40d2ca1f elementor-widget elementor-widget-image\" data-id=\"40d2ca1f\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<a href=\"http:\/\/ciba-usa.com\/es\/\">\n\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"362\" height=\"362\" src=\"https:\/\/ciba-usa.com\/wp-content\/uploads\/2024\/05\/14_minimalista_03_Logo-1.png\" class=\"attachment-large size-large wp-image-704\" alt=\"\" srcset=\"https:\/\/ciba-usa.com\/wp-content\/uploads\/2024\/05\/14_minimalista_03_Logo-1.png 362w, https:\/\/ciba-usa.com\/wp-content\/uploads\/2024\/05\/14_minimalista_03_Logo-1-300x300.png 300w, https:\/\/ciba-usa.com\/wp-content\/uploads\/2024\/05\/14_minimalista_03_Logo-1-100x100.png 100w\" sizes=\"(max-width: 362px) 100vw, 362px\" \/>\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-73d8c22e elementor-widget elementor-widget-heading\" data-id=\"73d8c22e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Cuestionario de Salud<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-57097d84 elementor-widget elementor-widget-heading\" data-id=\"57097d84\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Comience su viaje de p\u00e9rdida de peso hoy completando nuestro Formulario de salud. <\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-50bf3166 elementor-widget elementor-widget-spacer\" data-id=\"50bf3166\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2ffcc960 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"2ffcc960\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Health Questionnaire\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"708\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"2ffcc960\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Ciba USA\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_3a05357 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2eafbcb elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2eafbcb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tApellido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2eafbcb]\" id=\"form-field-field_2eafbcb\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_76e3973 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_76e3973\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_76e3973]\" id=\"form-field-field_76e3973\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c8d769d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c8d769d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tM\u00e9todo de Contacto Preferido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c8d769d]\" id=\"form-field-field_c8d769d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Text\">Texto<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Call\">Llamada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Email\">Correo electr\u00f3nico<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5b97a91 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5b97a91\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5b97a91]\" id=\"form-field-field_5b97a91\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-message elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFecha de nacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[message]\" id=\"form-field-message\" class=\"elementor-field elementor-size-xs  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1924-02-26\" max=\"2024-02-26\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_dbe9f13 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dbe9f13\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEdad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_dbe9f13]\" id=\"form-field-field_dbe9f13\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"1\" max=\"100\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a24ef12 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a24ef12\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tG\u00e9nero\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a24ef12]\" id=\"form-field-field_a24ef12\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Hombre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Mujer<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Another\">Otro<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_affd427 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_affd427\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAltura en Pies\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_affd427]\" id=\"form-field-field_affd427\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_1bc5d6c elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1bc5d6c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAltura pulgadas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_1bc5d6c]\" id=\"form-field-field_1bc5d6c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_d4f2111 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d4f2111\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPeso actual (libras)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_d4f2111]\" id=\"form-field-field_d4f2111\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"1\" max=\"600\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e1ddf1d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e817eba elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e817eba\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQu\u00e9 tan lejos est\u00e1s en el proceso?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e817eba]\" id=\"form-field-field_e817eba\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tIm ready to schedule \">a) Estoy listo para programar <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tI have questions \">b) tengo preguntas <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"c)\tJust researching my options\">c) Solo estoy investigando mis opciones<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"d)\tLooking for a surgeon \">d) Buscando una cirujana(femenino) <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_23171af elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_23171af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPreferencia del cirujano                                                        \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_23171af]\" id=\"form-field-field_23171af\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tNo preference \">a) Sin preferencia <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tDr. Zavalza\">b)\tDr. Zavalza<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"c)\tDr. Paipillla\">c)\tDr. Paipillla<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"d)\tDr. Rosales \">d)\tDr. Rosales <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_404503b elementor-col-100\">\n\t\t\t\t\t<style>\n  .body #options {\n   background-color: transparent; }\n\n   #options{\n    width: 100%;\n    height: 1.8rem; \n    padding: 0 0 0 0.4rem;\n    box-sizing: border-box;\n    color: #4B4F58;\n    font-weight: 400;\n    background-color: transparent;\n    border-color: #69727d;\n    font-family: Outfit;\n}\n    #otherComments{\n     background-color: transparent;\n     height: 30px; width: 100%; \n     border-color: #2E2E2E;\n\n     }\n\n#otherOption{\ncolor: #212E5C;\nmargin: 10px 0px\n}\n\n<\/style>\n\n<form>\n  <label for=\"options\">Inter\u00e9s de cirug\u00eda<span style=\"color: red;\"> *<\/span><\/label><br>\n  <select id=\"options\" name=\"options\" required>\n    <option value=\"undecided\" selected>A) Indecisa(o)<\/option>\n    <option value=\"gastric_sleeve\">b) Manga G\u00e1strica<\/option>\n    <option value=\"gastric_bypass\">c) Bypass g\u00e1strico<\/option>\n    <option value=\"mini_gastric_bypass\">d) Mini bypass g\u00e1strico<\/option>\n    <option value=\"bariatric_revision\">e) Revisi\u00f3n bari\u00e1trica<\/option>\n    <option value=\"single_incision_gastric_sleeve\">f) Manga g\u00e1strica de incisi\u00f3n \u00fanica<\/option>\n    <option value=\"other\">g) Otros <\/option>\n  <\/select>\n  \n  <!-- Campo de texto adicional para la opci\u00f3n \"Other\" -->\n  <div id=\"otherOption\" style=\"display:none;\">\n    <label for=\"otherComments\">Especificar:<\/label>\n    <input type=\"text\" id=\"otherComments\" name=\"otherComments\">\n  <\/div>\n<\/form>\n\n<script>\n  \/\/ Funci\u00f3n para mostrar el campo de texto adicional si se selecciona \"Other\"\n  document.getElementById('options').addEventListener('change', function() {\n    var otherOptionDiv = document.getElementById('otherOption');\n    if (this.value === 'other') {\n      otherOptionDiv.style.display = 'block';\n    } else {\n      otherOptionDiv.style.display = 'none';\n    }\n  });\n<\/script>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_744065c elementor-col-100\">\n\t\t\t\t\t<style>\n    .body #options1 {\n     background-color: transparent; }\n  \n     #options1{\n      width: 100%;\n      height: 1.8rem; \n      padding: 0 0 0 0.4rem;\n      box-sizing: border-box;\n      color: #4B4F58;\n      font-weight: 400;\n      background-color: transparent;\n      border-color: #69727d;\n      font-family: Outfit;\n\n  }\n      #otherComments1{\n       background-color: transparent;\n       height: 30px; width: 100%; \n       border-color: #2E2E2E;\n  \n       }\n  \n  #otherOption1{\n  color: #212E5C;\n  margin: 10px 0px\n  }\n  \n  <\/style>\n  \n \n \n \n  \n  \n  <form>\n    <label for=\"options\" style=\"color: #212E5C\">Tr\u00e1mites Adicionales de Inter\u00e9s<span style=\"color: red;\"> *<\/span><\/label><br>\n    <select id=\"options1\" name=\"options\" required>\n      <option value=\"undecided\" selected>a) Quitar la ves\u00edcula biliar<\/option>\n      <option value=\"gastric_sleeve\"> b) Reparaci\u00f3n de hernia de hiato <\/option>\n      <option value=\"gastric_bypass\"> c) Reparaci\u00f3n de hernia umbilical <\/option>\n      <option value=\"mini_gastric_bypass\"> d)\tNo <\/option>\n\n      <option value=\"other\">e) Otros <\/option>\n    <\/select>\n    \n    <!-- Campo de texto adicional para la opci\u00f3n \"Other\" -->\n    <div id=\"otherOption1\" style=\"display:none;\">\n      <label for=\"otherComments\">Especificar:<\/label>\n      <input type=\"text\" id=\"otherComments1\" name=\"otherComments\">\n    <\/div>\n  <\/form>\n  \n  <script>\n    \/\/ Funci\u00f3n para mostrar el campo de texto adicional si se selecciona \"Other\"\n    document.getElementById('options1').addEventListener('change', function() {\n      var otherOptionDiv = document.getElementById('otherOption1');\n      if (this.value === 'other') {\n        otherOptionDiv.style.display = 'block';\n      } else {\n        otherOptionDiv.style.display = 'none';\n      }\n    });\n  <\/script>\n  \t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_7bb7a3e elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7bb7a3e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFecha estimada de la cirug\u00eda. \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_7bb7a3e]\" id=\"form-field-field_7bb7a3e\" class=\"elementor-field elementor-size-xs  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"2024-02-26\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_1851b47 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_14c1255 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14c1255\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCondiciones gastrointestinales\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tUlcers\" id=\"form-field-field_14c1255-0\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-0\">a) \u00dalceras<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tHiatal hernia \" id=\"form-field-field_14c1255-1\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-1\">b) hernia de hiato <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tLiver or gallbladder problems\" id=\"form-field-field_14c1255-2\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-2\">c) Problemas de h\u00edgado o ves\u00edcula biliar<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tBowel irregularities\" id=\"form-field-field_14c1255-3\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-3\">d) irregularidades intestinales<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tColitis \" id=\"form-field-field_14c1255-4\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-4\">e)\tColitis <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tChron disease \" id=\"form-field-field_14c1255-5\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-5\">f) Enfermedad de Chron <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tAbdominal pain \" id=\"form-field-field_14c1255-6\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-6\">g) dolor abdominal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"h)\tGERD\/heartburn \" id=\"form-field-field_14c1255-7\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-7\">h) ERGE\/pirosis <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"i)\tGastroparesis\" id=\"form-field-field_14c1255-8\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-8\">i) gastroparesia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"j)\tNone \" id=\"form-field-field_14c1255-9\" name=\"form_fields[field_14c1255][]\"> <label for=\"form-field-field_14c1255-9\">j) Ninguna <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_def4d4a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_def4d4a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi corresponde, escriba ERGE\/s\u00edntomas de acidez estomacal \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_def4d4a]\" id=\"form-field-field_def4d4a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Escribe si aplica\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_125687f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_125687f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfHa tenido una cirug\u00eda de p\u00e9rdida de peso previa?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_125687f-0\" name=\"form_fields[field_125687f]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_125687f-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_125687f-1\" name=\"form_fields[field_125687f]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_125687f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_cb1158a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb1158a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProblemas del coraz\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tHeart valve problems\" id=\"form-field-field_cb1158a-0\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-0\">a) Problemas en las v\u00e1lvulas card\u00edacas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tAngina: Chest pain with physical activity \" id=\"form-field-field_cb1158a-1\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-1\">b) Angina: dolor en el pecho con la actividad f\u00edsica. <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tAnkle Swelling\" id=\"form-field-field_cb1158a-2\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-2\">c) Hinchaz\u00f3n del tobillo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tHeart attack \" id=\"form-field-field_cb1158a-3\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-3\">d) Ataque al coraz\u00f3n <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tHigh blood pressure\" id=\"form-field-field_cb1158a-4\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-4\">e) Presi\u00f3n arterial alta<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tVaricose veins \" id=\"form-field-field_cb1158a-5\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-5\">f) Venas varicosas <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tIrregular heartbeat\" id=\"form-field-field_cb1158a-6\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-6\">g) Latidos card\u00edacos irregulares<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"h)\tPacemaker \" id=\"form-field-field_cb1158a-7\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-7\">h) Marcapasos <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"i)\tCongestive heart failure \" id=\"form-field-field_cb1158a-8\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-8\">i) Insuficiencia card\u00edaca congestiva <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"j)\tNone \" id=\"form-field-field_cb1158a-9\" name=\"form_fields[field_cb1158a][]\"> <label for=\"form-field-field_cb1158a-9\">j) Ninguna <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8140228 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8140228\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProblemas respiratorios\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tAsthma\" id=\"form-field-field_8140228-0\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-0\">a) Asma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tEmphysema \" id=\"form-field-field_8140228-1\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-1\">b) enfisema <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tPneumonia\/bronchitis \" id=\"form-field-field_8140228-2\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-2\">c) Neumon\u00eda\/bronquitis <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tCannot breath lying flat\" id=\"form-field-field_8140228-3\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-3\">D) No puede respirar acostado(a)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tShortness of breath\" id=\"form-field-field_8140228-4\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-4\">e) Dificultad para respirar<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tFrequent cough or colds\" id=\"form-field-field_8140228-5\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-5\">f) Tos frecuente o resfriados<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tPulmonary embolism \" id=\"form-field-field_8140228-6\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-6\">g) Embolia pulmonar <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"h)\tSnoring \" id=\"form-field-field_8140228-7\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-7\">h) Ronquidos <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"i)\tSleep apnea \" id=\"form-field-field_8140228-8\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-8\">i) Apnea del sue\u00f1o <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"j)\tUse CPAP or BiPAP machine \" id=\"form-field-field_8140228-9\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-9\">j) Utilice una m\u00e1quina CPAP o BiPAP <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"k)\tNone \" id=\"form-field-field_8140228-10\" name=\"form_fields[field_8140228][]\"> <label for=\"form-field-field_8140228-10\">k) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f424bca elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f424bca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCondiciones urinarias\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tKidney stones\" id=\"form-field-field_f424bca-0\" name=\"form_fields[field_f424bca][]\"> <label for=\"form-field-field_f424bca-0\">a) C\u00e1lculos renales<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tFrequent urination \" id=\"form-field-field_f424bca-1\" name=\"form_fields[field_f424bca][]\"> <label for=\"form-field-field_f424bca-1\">b) Micci\u00f3n frecuente <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tBladder control problems \" id=\"form-field-field_f424bca-2\" name=\"form_fields[field_f424bca][]\"> <label for=\"form-field-field_f424bca-2\">c) Problemas de control de la vejiga. <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tPainful urination \" id=\"form-field-field_f424bca-3\" name=\"form_fields[field_f424bca][]\"> <label for=\"form-field-field_f424bca-3\">d) Dolor al orinar <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tNone \" id=\"form-field-field_f424bca-4\" name=\"form_fields[field_f424bca][]\"> <label for=\"form-field-field_f424bca-4\">e) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d381d1e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d381d1e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCondiciones musculares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tBone\/joint problems\" id=\"form-field-field_d381d1e-0\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-0\">a) Problemas \u00f3seos\/articulares<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tBack\/neck pain \" id=\"form-field-field_d381d1e-1\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-1\">b) Dolor de espalda\/cuello <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tArthritis\/gout \" id=\"form-field-field_d381d1e-2\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-2\">c) Artritis\/gota <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tKnee\/hip surgery \" id=\"form-field-field_d381d1e-3\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-3\">d) Cirug\u00eda de rodilla\/cadera <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tLupus \" id=\"form-field-field_d381d1e-4\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-4\">e)\tLupus <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tFibromyalgia \" id=\"form-field-field_d381d1e-5\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-5\">f) Fibromialgia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tNone \" id=\"form-field-field_d381d1e-6\" name=\"form_fields[field_d381d1e][]\"> <label for=\"form-field-field_d381d1e-6\">g) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6c55131 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6c55131\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCondiciones neurol\u00f3gicas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tDizziness\" id=\"form-field-field_6c55131-0\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-0\">a) Mareos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tMigraine headaches \" id=\"form-field-field_6c55131-1\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-1\">b) Migra\u00f1as <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tSleep apnea\" id=\"form-field-field_6c55131-2\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-2\">c) Apnea del sue\u00f1o<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tStroke in the past \" id=\"form-field-field_6c55131-3\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-3\">d) Accidente cerebrovascular en el pasado <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tSeizures\" id=\"form-field-field_6c55131-4\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-4\">e) Convulsiones<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tNone \" id=\"form-field-field_6c55131-5\" name=\"form_fields[field_6c55131][]\"> <label for=\"form-field-field_6c55131-5\">f) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_10be14e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_10be14e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTrastornos de la sangre\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tAnemia (iron deficient)\" id=\"form-field-field_10be14e-0\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-0\">a) Anemia (deficiencia de hierro)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tAnemia (B12 deficient \" id=\"form-field-field_10be14e-1\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-1\">b) Anemia (deficiencia de B12 <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tLow platelets \" id=\"form-field-field_10be14e-2\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-2\">c) Plaquetas bajas <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tBlood thinner use \" id=\"form-field-field_10be14e-3\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-3\">d) Uso de anticoagulantes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tDeep Blood Clot in Leg \" id=\"form-field-field_10be14e-4\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-4\">e) Co\u00e1gulo de sangre profundo en la pierna <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tBlood Clot in Lungs (Pulmonary Embolism) Bleeding disorder \" id=\"form-field-field_10be14e-5\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-5\">f) Co\u00e1gulo de sangre en los pulmones (embolia pulmonar) Trastorno hemorr\u00e1gico <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tBlood transfusion needed\" id=\"form-field-field_10be14e-6\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-6\">g) Se necesita transfusi\u00f3n de sangre<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"h)\tLymphoma \" id=\"form-field-field_10be14e-7\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-7\">h) Linfoma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"i)\tNone \" id=\"form-field-field_10be14e-8\" name=\"form_fields[field_10be14e][]\"> <label for=\"form-field-field_10be14e-8\">i)\tNinguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2528f18 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2528f18\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCondiciones endocrinas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tDiabetes \" id=\"form-field-field_2528f18-0\" name=\"form_fields[field_2528f18][]\"> <label for=\"form-field-field_2528f18-0\">a)\tDiabetes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tPre diabetes \" id=\"form-field-field_2528f18-1\" name=\"form_fields[field_2528f18][]\"> <label for=\"form-field-field_2528f18-1\">b)\tPre diabetes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tThryroid problems\" id=\"form-field-field_2528f18-2\" name=\"form_fields[field_2528f18][]\"> <label for=\"form-field-field_2528f18-2\">c) Problemas de tiroides<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tPCOS \" id=\"form-field-field_2528f18-3\" name=\"form_fields[field_2528f18][]\"> <label for=\"form-field-field_2528f18-3\">d) s\u00edndrome de ovario poliqu\u00edstico <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tNone \" id=\"form-field-field_2528f18-4\" name=\"form_fields[field_2528f18][]\"> <label for=\"form-field-field_2528f18-4\">e) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b2dc7ad elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b2dc7ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPsiqui\u00e1trico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"a)\tAnxiety \" id=\"form-field-field_b2dc7ad-0\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-0\">a) Ansiedad <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"b)\tDepression \" id=\"form-field-field_b2dc7ad-1\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-1\">b) depresi\u00f3n <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"c)\tBipolar disorder\" id=\"form-field-field_b2dc7ad-2\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-2\">c) Trastorno bipolar<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"d)\tAlcoholism \" id=\"form-field-field_b2dc7ad-3\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-3\">d) Alcoholismo <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"e)\tDrug dependency\" id=\"form-field-field_b2dc7ad-4\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-4\">e) Dependencia de drogas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"f)\tSchizophrenia \" id=\"form-field-field_b2dc7ad-5\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-5\">f) esquizofrenia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"g)\tNone \" id=\"form-field-field_b2dc7ad-6\" name=\"form_fields[field_b2dc7ad][]\"> <label for=\"form-field-field_b2dc7ad-6\">g) Ninguno <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_47e5045 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_47e5045\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tC\u00e1ncer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_47e5045-0\" name=\"form_fields[field_47e5045]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_47e5045-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_47e5045-1\" name=\"form_fields[field_47e5045]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_47e5045-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4a6210e elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a6210e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEspecificar\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4a6210e]\" id=\"form-field-field_4a6210e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4a49fc2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a49fc2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlguna vez ha tenido hepatitis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4a49fc2]\" id=\"form-field-field_4a49fc2\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tNo \">a)\tNo <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tHepatitis B\">b)\tHepatitis B<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"c)\tHepatitis C\">c)\tHepatitis C<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"d)\tBoth \">d)\tAmbos <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_806ef44 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_806ef44\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVIH\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_806ef44-0\" name=\"form_fields[field_806ef44]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_806ef44-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_806ef44-1\" name=\"form_fields[field_806ef44]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_806ef44-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e2225c2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e2225c2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfRechazas la sangre?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_e2225c2-0\" name=\"form_fields[field_e2225c2]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_e2225c2-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_e2225c2-1\" name=\"form_fields[field_e2225c2]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_e2225c2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0437c8c elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ed4b96f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ed4b96f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCirug\u00edas previas (enumere todas las cirug\u00edas, fecha, tipo de cirug\u00eda, cualquier complicaci\u00f3n) \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ed4b96f]\" id=\"form-field-field_ed4b96f\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_11c5a61 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_11c5a61\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOtras condiciones m\u00e9dicas no enumeradas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_11c5a61]\" id=\"form-field-field_11c5a61\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_32d81fc elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_32d81fc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfMedicamentos o suplementos? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_32d81fc]\" id=\"form-field-field_32d81fc\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6c26b36 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bd6179a elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bd6179a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCon qu\u00e9 frecuencia comes dulces?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_bd6179a]\" id=\"form-field-field_bd6179a\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tEveryday\">a) todos los d\u00edas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tOnce a week\">b) Una vez a la semana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"c)\t2 to 3 times a month \">c) 2 a 3 veces al mes <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"d)\tOnce a month \">d) Una vez al mes <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"e)\tOther \">e) Otros <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a86c26d elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a86c26d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQu\u00e9 tan seguido comes comida r\u00e1pida?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a86c26d]\" id=\"form-field-field_a86c26d\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tEveryday\">a) todos los d\u00edas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tOnce a week\">b) Una vez a la semana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"c)\t2 to 3 times a month \">c) 2 a 3 veces al mes <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"d)\tOnce a month \">d) Una vez al mes <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"e)\tOther \">e) Otros <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a13faf1 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a13faf1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfBebes alcohol?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a13faf1]\" id=\"form-field-field_a13faf1\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_849d772 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_849d772\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfBebes productos con cafe\u00edna?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_849d772]\" id=\"form-field-field_849d772\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4fc5d16 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4fc5d16\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfFuma o usa productos con nicotina? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4fc5d16]\" id=\"form-field-field_4fc5d16\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7dd3be9 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7dd3be9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUtilizas productos de marihuana? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7dd3be9]\" id=\"form-field-field_7dd3be9\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9c0b603 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9c0b603\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUtiliza productos con aspirina? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9c0b603]\" id=\"form-field-field_9c0b603\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bec3cfa elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bec3cfa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUtilizas hormonas sexuales? (incluidos anticonceptivos o reemplazo hormonal)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_bec3cfa]\" id=\"form-field-field_bec3cfa\" class=\"elementor-field-textual elementor-size-xs\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"a)\tYes \">a)\tSi <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"b)\tNo \">b)\tNo <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_32f370d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_32f370d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOtras sustancias (Especificar)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_32f370d]\" id=\"form-field-field_32f370d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_50e4641 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_50e4641\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre de referencia (si corresponde)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_50e4641]\" id=\"form-field-field_50e4641\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_06df1b6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_06df1b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlgo m\u00e1s que quieras agregar?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_06df1b6]\" id=\"form-field-field_06df1b6\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6040ea9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_cf54368 elementor-col-100\">\n\t\t\t\t\t<h3>T\u00e9rminos y Condiciones<\/h3> <br>\n<p>Estas preguntas son importantes para que nuestros cirujanos determinen la mejor opci\u00f3n de cirug\u00eda para bajar de peso para usted. Completar este formulario no te compromete a nada. Es simplemente un paso que lo guiar\u00e1 en su viaje. Complete este formulario de manera completa y precisa.\nConfirmo que la informaci\u00f3n que proporcion\u00e9 en este cuestionario de salud es verdadera y precisa. Entiendo que si no soy sincero, mi cotizaci\u00f3n puede ser incorrecta y podr\u00eda haber consecuencias graves, incluidos malos resultados, complicaciones y riesgos para mi salud. Tambi\u00e9n puedo enfrentar cargos adicionales y la posibilidad de que mi cirug\u00eda sea cancelada sin reembolso.\nHe le\u00eddo y comprendido los T\u00e9rminos y Condiciones de la pol\u00edtica Financiera, de Dep\u00f3sito, Cancelaci\u00f3n y Reembolso, y la Pol\u00edtica de Privacidad de CIBA USA. Si me convierto en un paciente programado, acepto estos t\u00e9rminos.\nAl enviar este formulario, acepto recibir correos electr\u00f3nicos, llamadas telef\u00f3nicas y\/o SMS de CIBA USA.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_280a59f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_280a59f]\" id=\"form-field-field_280a59f\" class=\"elementor-field elementor-size-xs  elementor-acceptance-field\" required=\"required\" aria-required=\"true\">\n\t\t\t\t<label for=\"form-field-field_280a59f\">Leo y acepto los T\u00e9rminos y Condiciones<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_ae57432 elementor-col-100 recaptcha_v3-inline\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_ae57432\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LcjxP0pAAAAADPazrN718gGz_4IiAG_Tqnj-myH\" data-type=\"v3\" data-action=\"Form\" data-badge=\"inline\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-753fda2d elementor-widget elementor-widget-spacer\" data-id=\"753fda2d\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-29b4a71 elementor-widget elementor-widget-text-editor\" data-id=\"29b4a71\" data-element_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<p><a href=\"https:\/\/ciba-usa.com\/es\/\" data-wplink-url-error=\"true\"><span style=\"text-decoration: underline;\">Volver a la p\u00e1gina principal<\/span><\/a><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2e2e3d9 elementor-widget elementor-widget-spacer\" data-id=\"2e2e3d9\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"_joinchat":[],"footnotes":""},"class_list":["post-711","page","type-page","status-publish","hentry","entry","owp-thumbs-layout-horizontal","owp-btn-normal","owp-tabs-layout-horizontal","has-no-thumbnails","has-product-nav"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Health Questionnaire - Ciba USA<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/ciba-usa.com\/es\/health-questionnaire\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Health Questionnaire - Ciba USA\" \/>\n<meta property=\"og:url\" content=\"https:\/\/ciba-usa.com\/es\/health-questionnaire\/\" \/>\n<meta property=\"og:site_name\" content=\"Ciba USA\" \/>\n<meta property=\"article:modified_time\" content=\"2024-05-31T19:49:02+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/ciba-usa.com\/health-questionnaire\/\",\"url\":\"https:\/\/ciba-usa.com\/health-questionnaire\/\",\"name\":\"Health Questionnaire - 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