{"id":3084,"date":"2021-12-09T20:45:58","date_gmt":"2021-12-09T19:45:58","guid":{"rendered":"https:\/\/vidairsalud.com\/consultation\/"},"modified":"2025-04-17T13:03:07","modified_gmt":"2025-04-17T11:03:07","slug":"consultation","status":"publish","type":"page","link":"https:\/\/vidairsalud.com\/en\/consultation\/","title":{"rendered":"CONSULTATION"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3084\" class=\"elementor elementor-3084 elementor-656\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2c06d81 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2c06d81\" data-element_type=\"section\" data-e-type=\"section\">\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-6fcb89b\" data-id=\"6fcb89b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-cbd4c82 elementor-reverse-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"cbd4c82\" data-element_type=\"section\" data-e-type=\"section\">\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-802414e\" data-id=\"802414e\" 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-f3d7664 elementor-widget elementor-widget-heading\" data-id=\"f3d7664\" data-element_type=\"widget\" data-e-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\">IF YOU NEED A CONSULTATION<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6d21763 elementor-widget elementor-widget-text-editor\" data-id=\"6d21763\" 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<p>Request a consultation with VIDAIR&#8217;s specialists using the form below.<\/p>\n<p>After receiving your request, our team will contact you to arrange the appointment.<\/p>\n<p>If you need consultation for sleep disorder, please invest 15 minutes of your time to fill in the following questionnaire.<\/p>\n<p>All your personal data will be treated <strong>confidentially<\/strong> and only used by our professional team. This information will enable our team to create your medical history based on your past history and current condition. Detailed information is essential to elaborate a previous comprehensive study of your case in order to focus on your needs and optimize your consultation time.<\/p>\n\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-3b0db52 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"3b0db52\" data-element_type=\"widget\" data-e-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=\"Formulario consulta\" aria-label=\"Formulario consulta\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"3084\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3b0db52\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"CONSULTATION - Vidair - Respiratory patient care\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"3084\"\/>\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-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\tName and surname\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-sm  elementor-field-textual\" required=\"required\">\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-field_b4369f8 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_b4369f8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\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[field_b4369f8]\" id=\"form-field-field_b4369f8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" 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-email 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\tYour email address\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[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\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_64eed8c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_64eed8c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow did you hear about VIDAIR?\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<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_64eed8c]\" id=\"form-field-field_64eed8c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Referred by my doctor\">Referred by my doctor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Social media\">Social media<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Television\">Television<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Radio\">Radio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Press\">Press<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Street advertising\">Street advertising<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Friend \/ family member\">Friend \/ family member<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cl\u00ednica Vida Vigo\">Cl\u00ednica Vida Vigo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Others\">Others<\/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_eee5cbb 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_eee5cbb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tType of consultation requested:\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=\"radio\" value=\"Online\" id=\"form-field-field_eee5cbb-0\" name=\"form_fields[field_eee5cbb]\" required=\"required\"> <label for=\"form-field-field_eee5cbb-0\">Online<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Face-to-face in Vigo, Spain\" id=\"form-field-field_eee5cbb-1\" name=\"form_fields[field_eee5cbb]\" required=\"required\"> <label for=\"form-field-field_eee5cbb-1\">Face-to-face in Vigo, Spain<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Face-to-face in Santiago de los Caballeros, Rep. account\" id=\"form-field-field_eee5cbb-2\" name=\"form_fields[field_eee5cbb]\" required=\"required\"> <label for=\"form-field-field_eee5cbb-2\">Face-to-face in Santiago de los Caballeros, Rep. account<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-message 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-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReason for consultation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[message]\" id=\"form-field-message\" rows=\"4\" placeholder=\"Tell us why you would like a consultation at VIDAIR.\" required=\"required\"><\/textarea>\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_aca9f4c 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_aca9f4c]\" id=\"form-field-field_aca9f4c\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_aca9f4c\">I have read and accept the <a href=\"https:\/\/vidairsalud.com\/politica-de-privacidad\/\">Privacy Policy<\/a><\/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-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\">Send<\/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<\/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-aadbe9d elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-shortcode\" data-id=\"aadbe9d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div id=\"quform-9a10a6\" class=\"quform quform-6 quform-theme-minimal quform-support-page-caching quform-is-first-page\"><form id=\"quform-form-9a10a6\" class=\"quform-form quform-form-6\" action=\"\/en\/wp-json\/wp\/v2\/pages\/3084#quform-9a10a6\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:6,&quot;uniqueId&quot;:&quot;9a10a6&quot;,&quot;theme&quot;:&quot;minimal&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;45&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;214&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;355&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;341&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Referido por mi m\\u00e9dico&quot;}]},&quot;216&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Presencial en VIDAIR, Santiago de los Caballeros, RD.&quot;}]},&quot;215&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Online, por video-llamada &quot;},{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;3&quot;,&quot;value&quot;:&quot;Llamada telef\\u00f3nica&quot;}]},&quot;98&quot;:{&quot;action&quot;:false,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Neumolog\\u00eda general&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;Fisioterapia Respiratoria (FR)&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Bienestar Nutricional\\u00ae. 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qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-6\"><input type=\"hidden\" name=\"quform_form_id\" value=\"6\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"9a10a6\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/vidairsalud.com\/en\/wp-json\/wp\/v2\/pages\/3084\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"wTyoVJpc9d38CoLk0xlz0kuDLCqJFgPtGJ1GXrex\" \/><div class=\"quform-elements quform-elements-6 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-page-progress quform-page-progress-type-percentage\"><div class=\"quform-page-progress-bar\" style=\"width: 10%;\"><span class=\"quform-page-progress-text\"><span class=\"quform-page-progress-percentage\">10<\/span>%<\/span><\/div><\/div><div class=\"quform-element quform-element-page quform-page-1 quform-page-6_1 quform-cf quform-group-style-plain quform-first-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_7 quform-cf\"><div class=\"quform-spacer\"><h3>DATOS PERSONALES<\/h3><br \/>\nA continuaci\u00f3n le pediremos una serie de datos personales que nos ser\u00e1n de gran utilidad para darle de alta como paciente y poder programar una consulta.<\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_15 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_16\"><div class=\"quform-element quform-element-text quform-element-6_6 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_6\"><label class=\"quform-label-text\" for=\"quform_6_6_9a10a6\">Nombre y apellidos<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_6\"><div class=\"quform-input quform-input-text quform-input-6_6 quform-cf\"><input type=\"text\" id=\"quform_6_6_9a10a6\" name=\"quform_6_6\" class=\"quform-field quform-field-text quform-field-6_6\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_17\"><div class=\"quform-element quform-element-text quform-element-6_8 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_8\"><label class=\"quform-label-text\" for=\"quform_6_8_9a10a6\">Documento de identidad n\u00ba (C\u00e9dula \/ Pasaporte)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_8\"><div class=\"quform-input quform-input-text quform-input-6_8 quform-cf\"><input type=\"text\" id=\"quform_6_8_9a10a6\" name=\"quform_6_8\" class=\"quform-field quform-field-text quform-field-6_8\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_18 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_19\"><div class=\"quform-element quform-element-text quform-element-6_9 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_9\"><label class=\"quform-label-text\" for=\"quform_6_9_9a10a6\">Fecha de nacimiento<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_9\"><div class=\"quform-input quform-input-text quform-input-6_9 quform-cf\"><input type=\"text\" id=\"quform_6_9_9a10a6\" name=\"quform_6_9\" class=\"quform-field quform-field-text quform-field-6_9\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_20\"><div class=\"quform-element quform-element-text quform-element-6_22 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_22\"><label class=\"quform-label-text\" for=\"quform_6_22_9a10a6\">Edad<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_22\"><div class=\"quform-input quform-input-text quform-input-6_22 quform-cf\"><input type=\"text\" id=\"quform_6_22_9a10a6\" name=\"quform_6_22\" class=\"quform-field quform-field-text quform-field-6_22\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_23 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_24\"><div class=\"quform-element quform-element-text quform-element-6_25 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_25\"><label class=\"quform-label-text\" for=\"quform_6_25_9a10a6\">Estado civil<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_25\"><div class=\"quform-input quform-input-text quform-input-6_25 quform-cf\"><input type=\"text\" id=\"quform_6_25_9a10a6\" name=\"quform_6_25\" class=\"quform-field quform-field-text quform-field-6_25\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_26\"><div class=\"quform-element quform-element-text quform-element-6_27 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_27\"><label class=\"quform-label-text\" for=\"quform_6_27_9a10a6\">Profesi\u00f3n - oficio<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_27\"><div class=\"quform-input quform-input-text quform-input-6_27 quform-cf\"><input type=\"text\" id=\"quform_6_27_9a10a6\" name=\"quform_6_27\" class=\"quform-field quform-field-text quform-field-6_27\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_28 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_29\"><div class=\"quform-element quform-element-text quform-element-6_30 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_30\"><label class=\"quform-label-text\" for=\"quform_6_30_9a10a6\">Direcci\u00f3n<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_30\"><div class=\"quform-input quform-input-text quform-input-6_30 quform-cf\"><input type=\"text\" id=\"quform_6_30_9a10a6\" name=\"quform_6_30\" class=\"quform-field quform-field-text quform-field-6_30\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_31\"><div class=\"quform-element quform-element-text quform-element-6_32 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_32\"><label class=\"quform-label-text\" for=\"quform_6_32_9a10a6\">Tel\u00e9fono<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_32\"><div class=\"quform-input quform-input-text quform-input-6_32 quform-cf\"><input type=\"text\" id=\"quform_6_32_9a10a6\" name=\"quform_6_32\" class=\"quform-field quform-field-text quform-field-6_32\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_33 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_34\"><div class=\"quform-element quform-element-email quform-element-6_38 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_38\"><label class=\"quform-label-text\" for=\"quform_6_38_9a10a6\">Correo electr\u00f3nico<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-6_38\"><div class=\"quform-input quform-input-email quform-input-6_38 quform-cf\"><input type=\"email\" id=\"quform_6_38_9a10a6\" name=\"quform_6_38\" class=\"quform-field quform-field-email quform-field-6_38\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_36\"><div class=\"quform-element quform-element-radio quform-element-6_214 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_214\"><label class=\"quform-label-text\" id=\"quform_6_214_9a10a6_label\">\u00bfAcude a trav\u00e9s de su aseguradora?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_214\"><div class=\"quform-input quform-input-radio quform-input-6_214 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_214_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_214\" id=\"quform_6_214_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_214 quform-field-6_214_1\" value=\"SI\" \/><label for=\"quform_6_214_9a10a6_1\" class=\"quform-option-label quform-option-label-6_214_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_214\" id=\"quform_6_214_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_214 quform-field-6_214_2\" value=\"NO\" \/><label for=\"quform_6_214_9a10a6_2\" class=\"quform-option-label quform-option-label-6_214_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-6_45 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-6_46 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_47\"><div class=\"quform-element quform-element-select quform-element-6_342 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_342\"><label class=\"quform-label-text\" for=\"quform_6_342_9a10a6\">Seleccione su aseguradora<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-6_342\"><div class=\"quform-input quform-input-select quform-input-6_342 quform-cf\"><select id=\"quform_6_342_9a10a6\" name=\"quform_6_342\" class=\"quform-field quform-field-select quform-field-6_342\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Primera ARS de Humano\">Primera ARS de Humano<\/option><option value=\"Humano\">Humano<\/option><option value=\"ARS Universal\">ARS Universal<\/option><option value=\"MAPFRE SALUD ARS\">MAPFRE SALUD ARS<\/option><option value=\"ARS Yunen \">ARS Yunen <\/option><option value=\"ARS MONUMENTAL \">ARS MONUMENTAL <\/option><option value=\"WorldWide Seguros\">WorldWide Seguros<\/option><option value=\"ARS SIMAG\">ARS SIMAG<\/option><option value=\"SERVICIOS MEDICOS UASD\">SERVICIOS MEDICOS UASD<\/option><option value=\"APS ARS\">APS ARS<\/option><option value=\"FUTURO ARS \">FUTURO ARS <\/option><option value=\"MetaSalud ARS\">MetaSalud ARS<\/option><option value=\"ARS ASEMAP\">ARS ASEMAP<\/option><option value=\"SeNaSa Seguro Nacional de Salud.\">SeNaSa Seguro Nacional de Salud.<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_48\"><div class=\"quform-element quform-element-text quform-element-6_49 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_49\"><label class=\"quform-label-text\" for=\"quform_6_49_9a10a6\">N\u00famero de p\u00f3liza<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_49\"><div class=\"quform-input quform-input-text quform-input-6_49 quform-cf\"><input type=\"text\" id=\"quform_6_49_9a10a6\" name=\"quform_6_49\" class=\"quform-field quform-field-text quform-field-6_49\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-6_341 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_341\"><label class=\"quform-label-text\" for=\"quform_6_341_9a10a6\">\u00bfC\u00f3mo ha conocido VIDAIR?<\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-6_341\"><div class=\"quform-input quform-input-select quform-input-6_341 quform-cf\"><select id=\"quform_6_341_9a10a6\" name=\"quform_6_341\" class=\"quform-field quform-field-select quform-field-6_341\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Referido por mi m\u00e9dico\">Referido por mi m\u00e9dico<\/option><option value=\"Redes sociales\">Redes sociales<\/option><option value=\"Televisi\u00f3n \">Televisi\u00f3n <\/option><option value=\"Radio\">Radio<\/option><option value=\"Prensa\">Prensa<\/option><option value=\"Publicidad en la calle\">Publicidad en la calle<\/option><option value=\"Amigo \/ familiar \">Amigo \/ familiar <\/option><option value=\"Otros\">Otros<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-6_355 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_355\"><label class=\"quform-label-text\" for=\"quform_6_355_9a10a6\">Seleccione su m\u00e9dico<\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-6_355\"><div class=\"quform-input quform-input-select quform-input-6_355 quform-cf\"><select id=\"quform_6_355_9a10a6\" name=\"quform_6_355\" class=\"quform-field quform-field-select quform-field-6_355\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Robert Liriano Stambuly\">Robert Liriano Stambuly<\/option><option value=\"Dami\u00e1n Antonio Tavares Robiou\">Dami\u00e1n Antonio Tavares Robiou<\/option><option value=\"Jos\u00e9 Luis Mej\u00eda Vargas\">Jos\u00e9 Luis Mej\u00eda Vargas<\/option><option value=\"Corina Santos Jimenez \">Corina Santos Jimenez <\/option><option value=\"Rosanna Dur\u00e1n Dur\u00e1n \">Rosanna Dur\u00e1n Dur\u00e1n <\/option><option value=\"Lucia Genao \">Lucia Genao <\/option><option value=\"Juan Carlos Marcelino \">Juan Carlos Marcelino <\/option><option value=\"Natalis Tejada Vargas\">Natalis Tejada Vargas<\/option><option value=\"Luis Faringthon Reyes\">Luis Faringthon Reyes<\/option><option value=\"Mayren\u00ed Marte \">Mayren\u00ed Marte <\/option><option value=\"Carlos Manuel Brito Reynoso\">Carlos Manuel Brito Reynoso<\/option><option value=\"Alfa Kenia Fern\u00e1ndez\">Alfa Kenia Fern\u00e1ndez<\/option><option value=\"Angelina Fern\u00e1ndez \">Angelina Fern\u00e1ndez <\/option><option value=\"Amad\u00eds Maldonado \">Amad\u00eds Maldonado <\/option><option value=\"Alexandra Espinal\">Alexandra Espinal<\/option><option value=\"Samuel Hern\u00e1ndez\">Samuel Hern\u00e1ndez<\/option><option value=\"Miguel Adonis Mej\u00eda \">Miguel Adonis Mej\u00eda <\/option><option value=\"Miguel Estrella \">Miguel Estrella <\/option><option value=\"Minerva Espinal \">Minerva Espinal <\/option><option value=\"Elida Mar\u00eda Lantigua Caraballo\">Elida Mar\u00eda Lantigua Caraballo<\/option><option value=\"Katerine Jaqu\u00e9z\">Katerine Jaqu\u00e9z<\/option><option value=\" Victor M\u00e9ndez\"> Victor M\u00e9ndez<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-next quform-button-next-default quform-button-next-6_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-51 quform-page-6_51 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_52 quform-cf\"><div class=\"quform-spacer\"><h3>DETALLES DE LA PROGRAMACI\u00d3N<\/h3><br \/>\nA continuaci\u00f3n le preguntaremos sobre sus preferencias a la hora de agendar una consulta.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_211 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_211\"><label class=\"quform-label-text\" id=\"quform_6_211_9a10a6_label\">Selecciones el d\u00eda  y la hora de su preferencia para la consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_211\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones.\n\n<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_211 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_211_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_211[]\" id=\"quform_6_211_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_211 quform-field-6_211_1\" value=\"Lunes\" \/><label for=\"quform_6_211_9a10a6_1\" class=\"quform-option-label quform-option-label-6_211_1\"><span class=\"quform-option-text\">Lunes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_211[]\" id=\"quform_6_211_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_211 quform-field-6_211_2\" value=\"Martes\" \/><label for=\"quform_6_211_9a10a6_2\" class=\"quform-option-label quform-option-label-6_211_2\"><span class=\"quform-option-text\">Martes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_211[]\" id=\"quform_6_211_9a10a6_3\" class=\"quform-field quform-field-checkbox quform-field-6_211 quform-field-6_211_3\" value=\"Mi\u00e9rcoles\" \/><label for=\"quform_6_211_9a10a6_3\" class=\"quform-option-label quform-option-label-6_211_3\"><span class=\"quform-option-text\">Mi\u00e9rcoles<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_211[]\" id=\"quform_6_211_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_211 quform-field-6_211_4\" value=\"Jueves\" \/><label for=\"quform_6_211_9a10a6_4\" class=\"quform-option-label quform-option-label-6_211_4\"><span class=\"quform-option-text\">Jueves<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_211[]\" id=\"quform_6_211_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_211 quform-field-6_211_5\" value=\"Viernes\" \/><label for=\"quform_6_211_9a10a6_5\" class=\"quform-option-label quform-option-label-6_211_5\"><span class=\"quform-option-text\">Viernes<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_212 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_212\"><label class=\"quform-label-text\" id=\"quform_6_212_9a10a6_label\">\u00bfDurante cual tanda desea su cita?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_212\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones.\n\n<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_212 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_212_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_212[]\" id=\"quform_6_212_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_212 quform-field-6_212_1\" value=\"Ma\u00f1ana de 7:30 am a 12:00 m\" \/><label for=\"quform_6_212_9a10a6_1\" class=\"quform-option-label quform-option-label-6_212_1\"><span class=\"quform-option-text\">Ma\u00f1ana de 7:30 am a 12:00 m<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_212[]\" id=\"quform_6_212_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_212 quform-field-6_212_2\" value=\"Tarde de 1:00 pm a 6:00 pm\" \/><label for=\"quform_6_212_9a10a6_2\" class=\"quform-option-label quform-option-label-6_212_2\"><span class=\"quform-option-text\">Tarde de 1:00 pm a 6:00 pm<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_212[]\" id=\"quform_6_212_9a10a6_3\" class=\"quform-field quform-field-checkbox quform-field-6_212 quform-field-6_212_3\" value=\"Noche de 7:00 pm a 8:30 pm\" \/><label for=\"quform_6_212_9a10a6_3\" class=\"quform-option-label quform-option-label-6_212_3\"><span class=\"quform-option-text\">Noche de 7:00 pm a 8:30 pm<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_115 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_115\"><label class=\"quform-label-text\" id=\"quform_6_115_9a10a6_label\">\u00bfC\u00f3mo desea realizar su consulta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_115\"><div class=\"quform-input quform-input-radio quform-input-6_115 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_115_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_115\" id=\"quform_6_115_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_115 quform-field-6_115_1\" value=\"Presencial en VIDAIR, Santiago de los Caballeros, RD.\" \/><label for=\"quform_6_115_9a10a6_1\" class=\"quform-option-label quform-option-label-6_115_1\"><span class=\"quform-option-text\">Presencial en VIDAIR, Santiago de los Caballeros, RD.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_115\" id=\"quform_6_115_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_115 quform-field-6_115_2\" value=\"Online, por video-llamada \" \/><label for=\"quform_6_115_9a10a6_2\" class=\"quform-option-label quform-option-label-6_115_2\"><span class=\"quform-option-text\">Online, por video-llamada <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_115\" id=\"quform_6_115_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_115 quform-field-6_115_3\" value=\"Llamada telef\u00f3nica\" \/><label for=\"quform_6_115_9a10a6_3\" class=\"quform-option-label quform-option-label-6_115_3\"><span class=\"quform-option-text\">Llamada telef\u00f3nica<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_216 quform-cf\"><div class=\"quform-spacer\">Recuerde que el uso de la mascarilla es obligatorio todo el tiempo que permanezca dentro de las instalaciones de VIDAIR. Seg\u00fan sea la situaci\u00f3n epidemiol\u00f3gica en la Rep. Dominicana, para las consultas presenciales, por favor, consulte a trav\u00e9s del 0000000000 si es posible acudir acompa\u00f1ado\/a.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_215 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-checkbox quform-inner-6_215\"><div class=\"quform-input quform-input-checkbox quform-input-6_215 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_215[]\" id=\"quform_6_215_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_215 quform-field-6_215_1\" value=\"He recibido por parte de VIDAIR como paciente y\/o familiar o tutor, la advertencia sobre la idoneidad de concertar una cita presencial, y los riesgos e inconvenientes tanto para m\u00ed como paciente, como para el profesional de VIDAIR, de una consulta m\u00e9dica bajo estas circunstancias, no obstante, he decidido concertar mi cita online asumiendo estos riesgos e inconvenientes.   &lt;br \/&gt;Este tipo de consulta, est\u00e1 basado en la informaci\u00f3n que aporta  el paciente y\/o familiar o tutor de forma verbal. Al no ser presencial - v\u00eda telef\u00f3nica, no es posible realizar por parte del\/la m\u00e9dico\/a especialista un examen f\u00edsico que incluya el aspecto general del paciente, los signos cl\u00ednicos que pueda presentar, toma de constantes vitales, ni la realizaci\u00f3n de una exploraci\u00f3n f\u00edsica. Por lo que el juicio diagn\u00f3stico elaborado por el profesional, podr\u00eda no ser concluyente. VIDAIR no se responsabiliza de perjuicios o da\u00f1os de cualquier naturaleza que pudieran presentarse ante la falta de datos cl\u00ednicos, exactitud, autenticidad y\/o exhaustividad de toda la informaci\u00f3n aportada por  el o la paciente, su familiar o tutor legal, para una correcta prestaci\u00f3n del servicio,  y especialmente, por cualquier  da\u00f1o y perjuicio resultado de la suplantaci\u00f3n de personalidad por otra persona, en nombre del o la paciente durante la consulta online, especialmente modo telef\u00f3nica. \" \/><label for=\"quform_6_215_9a10a6_1\" class=\"quform-option-label quform-option-label-6_215_1\"><span class=\"quform-option-text\">He recibido por parte de VIDAIR como paciente y\/o familiar o tutor, la advertencia sobre la idoneidad de concertar una cita presencial, y los riesgos e inconvenientes tanto para m\u00ed como paciente, como para el profesional de VIDAIR, de una consulta m\u00e9dica bajo estas circunstancias, no obstante, he decidido concertar mi cita online asumiendo estos riesgos e inconvenientes.   <br \/>Este tipo de consulta, est\u00e1 basado en la informaci\u00f3n que aporta  el paciente y\/o familiar o tutor de forma verbal. Al no ser presencial - v\u00eda telef\u00f3nica, no es posible realizar por parte del\/la m\u00e9dico\/a especialista un examen f\u00edsico que incluya el aspecto general del paciente, los signos cl\u00ednicos que pueda presentar, toma de constantes vitales, ni la realizaci\u00f3n de una exploraci\u00f3n f\u00edsica. Por lo que el juicio diagn\u00f3stico elaborado por el profesional, podr\u00eda no ser concluyente. VIDAIR no se responsabiliza de perjuicios o da\u00f1os de cualquier naturaleza que pudieran presentarse ante la falta de datos cl\u00ednicos, exactitud, autenticidad y\/o exhaustividad de toda la informaci\u00f3n aportada por  el o la paciente, su familiar o tutor legal, para una correcta prestaci\u00f3n del servicio,  y especialmente, por cualquier  da\u00f1o y perjuicio resultado de la suplantaci\u00f3n de personalidad por otra persona, en nombre del o la paciente durante la consulta online, especialmente modo telef\u00f3nica. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_85 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_85\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_85\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-90 quform-page-6_90 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_91 quform-cf\"><div class=\"quform-spacer\"><h3>MOTIVO DE SU CONSULTA<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_97 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_97\"><label class=\"quform-label-text\" id=\"quform_6_97_9a10a6_label\">\u00bfCu\u00e1l es la especialidad en la que desea una consulta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_97\"><div class=\"quform-input quform-input-checkbox quform-input-6_97 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_97_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_1\" value=\"Neumolog\u00eda general\" \/><label for=\"quform_6_97_9a10a6_1\" class=\"quform-option-label quform-option-label-6_97_1\"><span class=\"quform-option-text\">Neumolog\u00eda general<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_2\" value=\"Divisi\u00f3n Sue\u00f1o-Salud\u00ae. Trastornos respiratorios del sue\u00f1o y trastornos del sue\u00f1o\" \/><label for=\"quform_6_97_9a10a6_2\" class=\"quform-option-label quform-option-label-6_97_2\"><span class=\"quform-option-text\">Divisi\u00f3n Sue\u00f1o-Salud\u00ae. Trastornos respiratorios del sue\u00f1o y trastornos del sue\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_4\" value=\"Fisioterapia Respiratoria (FR)\" \/><label for=\"quform_6_97_9a10a6_4\" class=\"quform-option-label quform-option-label-6_97_4\"><span class=\"quform-option-text\">Fisioterapia Respiratoria (FR)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_5\" value=\"Soporte psicol\u00f3gico al paciente respiratorio y familiar o cuidador\" \/><label for=\"quform_6_97_9a10a6_5\" class=\"quform-option-label quform-option-label-6_97_5\"><span class=\"quform-option-text\">Soporte psicol\u00f3gico al paciente respiratorio y familiar o cuidador<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_6\" value=\"Bienestar Nutricional\u00ae. Sensibilidad alimentaria -microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico\" \/><label for=\"quform_6_97_9a10a6_6\" class=\"quform-option-label quform-option-label-6_97_6\"><span class=\"quform-option-text\">Bienestar Nutricional\u00ae. Sensibilidad alimentaria -microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_7\" value=\"Estudios y pruebas diagnosticas\" \/><label for=\"quform_6_97_9a10a6_7\" class=\"quform-option-label quform-option-label-6_97_7\"><span class=\"quform-option-text\">Estudios y pruebas diagnosticas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_8\" value=\"Experto Health Coach\" \/><label for=\"quform_6_97_9a10a6_8\" class=\"quform-option-label quform-option-label-6_97_8\"><span class=\"quform-option-text\">Experto Health Coach<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_97[]\" id=\"quform_6_97_9a10a6_9\" class=\"quform-field quform-field-checkbox quform-field-6_97 quform-field-6_97_9\" value=\"No lo s\u00e9 con seguridad\" \/><label for=\"quform_6_97_9a10a6_9\" class=\"quform-option-label quform-option-label-6_97_9\"><span class=\"quform-option-text\">No lo s\u00e9 con seguridad<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_98 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_98\"><label class=\"quform-label-text\" for=\"quform_6_98_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_98\"><div class=\"quform-input quform-input-textarea quform-input-6_98 quform-cf\"><textarea id=\"quform_6_98_9a10a6\" name=\"quform_6_98\" class=\"quform-field quform-field-textarea quform-field-6_98\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_95 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_95\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_95\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-217 quform-page-6_217 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_218 quform-cf\"><div class=\"quform-spacer\"><h3>Consulta Neumolog\u00eda general. Cuestionario consulta Neumolog\u00eda.<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_219 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_219\"><label class=\"quform-label-text\" id=\"quform_6_219_9a10a6_label\">Motivo de consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_219\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_219 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_219_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_1\" value=\"Tos\" \/><label for=\"quform_6_219_9a10a6_1\" class=\"quform-option-label quform-option-label-6_219_1\"><span class=\"quform-option-text\">Tos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_2\" value=\"Secreci\u00f3n nasal\" \/><label for=\"quform_6_219_9a10a6_2\" class=\"quform-option-label quform-option-label-6_219_2\"><span class=\"quform-option-text\">Secreci\u00f3n nasal<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_4\" value=\"Estornudos\" \/><label for=\"quform_6_219_9a10a6_4\" class=\"quform-option-label quform-option-label-6_219_4\"><span class=\"quform-option-text\">Estornudos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_5\" value=\"Obstrucci\u00f3n nasal\" \/><label for=\"quform_6_219_9a10a6_5\" class=\"quform-option-label quform-option-label-6_219_5\"><span class=\"quform-option-text\">Obstrucci\u00f3n nasal<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_6\" value=\"Expectoraci\u00f3n (mocos)\" \/><label for=\"quform_6_219_9a10a6_6\" class=\"quform-option-label quform-option-label-6_219_6\"><span class=\"quform-option-text\">Expectoraci\u00f3n (mocos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_7\" value=\"Expectoraci\u00f3n con sangre\" \/><label for=\"quform_6_219_9a10a6_7\" class=\"quform-option-label quform-option-label-6_219_7\"><span class=\"quform-option-text\">Expectoraci\u00f3n con sangre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_8\" value=\"Fiebre\" \/><label for=\"quform_6_219_9a10a6_8\" class=\"quform-option-label quform-option-label-6_219_8\"><span class=\"quform-option-text\">Fiebre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_9\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_9\" value=\"Dolor de pecho\" \/><label for=\"quform_6_219_9a10a6_9\" class=\"quform-option-label quform-option-label-6_219_9\"><span class=\"quform-option-text\">Dolor de pecho<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_10\" value=\"Dificultad respiratoria\" \/><label for=\"quform_6_219_9a10a6_10\" class=\"quform-option-label quform-option-label-6_219_10\"><span class=\"quform-option-text\">Dificultad respiratoria<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_11\" value=\"Sibilancias (pitos al respirar)\" \/><label for=\"quform_6_219_9a10a6_11\" class=\"quform-option-label quform-option-label-6_219_11\"><span class=\"quform-option-text\">Sibilancias (pitos al respirar)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_12\" value=\"Ronquido\" \/><label for=\"quform_6_219_9a10a6_12\" class=\"quform-option-label quform-option-label-6_219_12\"><span class=\"quform-option-text\">Ronquido<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_13\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_13\" value=\"Sospecha de COVID 19\" \/><label for=\"quform_6_219_9a10a6_13\" class=\"quform-option-label quform-option-label-6_219_13\"><span class=\"quform-option-text\">Sospecha de COVID 19<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_219[]\" id=\"quform_6_219_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_219 quform-field-6_219_14\" value=\"Otros\" \/><label for=\"quform_6_219_9a10a6_14\" class=\"quform-option-label quform-option-label-6_219_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_220 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_220\"><label class=\"quform-label-text\" for=\"quform_6_220_9a10a6\">Enumere sus otros s\u00edntomas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_220\"><div class=\"quform-input quform-input-textarea quform-input-6_220 quform-cf\"><textarea id=\"quform_6_220_9a10a6\" name=\"quform_6_220\" class=\"quform-field quform-field-textarea quform-field-6_220\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_222 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_222\"><label class=\"quform-label-text\" id=\"quform_6_222_9a10a6_label\">Antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_222\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_222 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_222_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_1\" value=\"Obesidad\" \/><label for=\"quform_6_222_9a10a6_1\" class=\"quform-option-label quform-option-label-6_222_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_222_9a10a6_2\" class=\"quform-option-label quform-option-label-6_222_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_222_9a10a6_4\" class=\"quform-option-label quform-option-label-6_222_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_222_9a10a6_5\" class=\"quform-option-label quform-option-label-6_222_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_222_9a10a6_6\" class=\"quform-option-label quform-option-label-6_222_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_7\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_6_222_9a10a6_7\" class=\"quform-option-label quform-option-label-6_222_7\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_15\" value=\"Enfisema\" \/><label for=\"quform_6_222_9a10a6_15\" class=\"quform-option-label quform-option-label-6_222_15\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_222_9a10a6_8\" class=\"quform-option-label quform-option-label-6_222_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_9\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_9\" value=\"Enfermedades autoimunes\" \/><label for=\"quform_6_222_9a10a6_9\" class=\"quform-option-label quform-option-label-6_222_9\"><span class=\"quform-option-text\">Enfermedades autoimunes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_222_9a10a6_10\" class=\"quform-option-label quform-option-label-6_222_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_222_9a10a6_11\" class=\"quform-option-label quform-option-label-6_222_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_222_9a10a6_12\" class=\"quform-option-label quform-option-label-6_222_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_222[]\" id=\"quform_6_222_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_222 quform-field-6_222_14\" value=\"Otros\" \/><label for=\"quform_6_222_9a10a6_14\" class=\"quform-option-label quform-option-label-6_222_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_223 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_223\"><label class=\"quform-label-text\" for=\"quform_6_223_9a10a6\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_223\"><div class=\"quform-input quform-input-textarea quform-input-6_223 quform-cf\"><textarea id=\"quform_6_223_9a10a6\" name=\"quform_6_223\" class=\"quform-field quform-field-textarea quform-field-6_223\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_224 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_224\"><label class=\"quform-label-text\" id=\"quform_6_224_9a10a6_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_224\"><div class=\"quform-input quform-input-radio quform-input-6_224 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_224_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_224\" id=\"quform_6_224_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_224 quform-field-6_224_1\" value=\"No\" \/><label for=\"quform_6_224_9a10a6_1\" class=\"quform-option-label quform-option-label-6_224_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_224\" id=\"quform_6_224_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_224 quform-field-6_224_2\" value=\"Si\" \/><label for=\"quform_6_224_9a10a6_2\" class=\"quform-option-label quform-option-label-6_224_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_225 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_225\"><label class=\"quform-label-text\" for=\"quform_6_225_9a10a6\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_225\"><div class=\"quform-input quform-input-text quform-input-6_225 quform-cf\"><input type=\"text\" id=\"quform_6_225_9a10a6\" name=\"quform_6_225\" class=\"quform-field quform-field-text quform-field-6_225\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_226 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_226\"><label class=\"quform-label-text\" id=\"quform_6_226_9a10a6_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_226\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_226 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_226_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_1\" value=\"Obesidad\" \/><label for=\"quform_6_226_9a10a6_1\" class=\"quform-option-label quform-option-label-6_226_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_226_9a10a6_2\" class=\"quform-option-label quform-option-label-6_226_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_226_9a10a6_4\" class=\"quform-option-label quform-option-label-6_226_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_226_9a10a6_5\" class=\"quform-option-label quform-option-label-6_226_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_226_9a10a6_11\" class=\"quform-option-label quform-option-label-6_226_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_226_9a10a6_6\" class=\"quform-option-label quform-option-label-6_226_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_226_9a10a6_8\" class=\"quform-option-label quform-option-label-6_226_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_226_9a10a6_10\" class=\"quform-option-label quform-option-label-6_226_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_226_9a10a6_12\" class=\"quform-option-label quform-option-label-6_226_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_226[]\" id=\"quform_6_226_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_226 quform-field-6_226_14\" value=\"Otros\" \/><label for=\"quform_6_226_9a10a6_14\" class=\"quform-option-label quform-option-label-6_226_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_227 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_227\"><label class=\"quform-label-text\" for=\"quform_6_227_9a10a6\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_227\"><div class=\"quform-input quform-input-textarea quform-input-6_227 quform-cf\"><textarea id=\"quform_6_227_9a10a6\" name=\"quform_6_227\" class=\"quform-field quform-field-textarea quform-field-6_227\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_228 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_229 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_229\"><label class=\"quform-label-text\" id=\"quform_6_229_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_229\"><div class=\"quform-input quform-input-radio quform-input-6_229 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_229_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_229\" id=\"quform_6_229_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_229 quform-field-6_229_2\" value=\"Si\" \/><label for=\"quform_6_229_9a10a6_2\" class=\"quform-option-label quform-option-label-6_229_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_229\" id=\"quform_6_229_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_229 quform-field-6_229_1\" value=\"No\" \/><label for=\"quform_6_229_9a10a6_1\" class=\"quform-option-label quform-option-label-6_229_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_229\" id=\"quform_6_229_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_229 quform-field-6_229_5\" value=\"Ex fumador\/a\" \/><label for=\"quform_6_229_9a10a6_5\" class=\"quform-option-label quform-option-label-6_229_5\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_344 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_344\"><label class=\"quform-label-text\" for=\"quform_6_344_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_344\"><div class=\"quform-input quform-input-text quform-input-6_344 quform-cf\"><input type=\"text\" id=\"quform_6_344_9a10a6\" name=\"quform_6_344\" class=\"quform-field quform-field-text quform-field-6_344\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_230 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_230\"><label class=\"quform-label-text\" id=\"quform_6_230_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_230\"><div class=\"quform-input quform-input-radio quform-input-6_230 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_230_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_230\" id=\"quform_6_230_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_230 quform-field-6_230_2\" value=\"Si\" \/><label for=\"quform_6_230_9a10a6_2\" class=\"quform-option-label quform-option-label-6_230_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_230\" id=\"quform_6_230_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_230 quform-field-6_230_1\" value=\"No\" \/><label for=\"quform_6_230_9a10a6_1\" class=\"quform-option-label quform-option-label-6_230_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_345 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_345\"><label class=\"quform-label-text\" for=\"quform_6_345_9a10a6\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_345\"><div class=\"quform-input quform-input-text quform-input-6_345 quform-cf\"><input type=\"text\" id=\"quform_6_345_9a10a6\" name=\"quform_6_345\" class=\"quform-field quform-field-text quform-field-6_345\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_231 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_231\"><label class=\"quform-label-text\" id=\"quform_6_231_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_231\"><div class=\"quform-input quform-input-radio quform-input-6_231 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_231_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_231\" id=\"quform_6_231_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_231 quform-field-6_231_2\" value=\"Si\" \/><label for=\"quform_6_231_9a10a6_2\" class=\"quform-option-label quform-option-label-6_231_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_231\" id=\"quform_6_231_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_231 quform-field-6_231_1\" value=\"No\" \/><label for=\"quform_6_231_9a10a6_1\" class=\"quform-option-label quform-option-label-6_231_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_232 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_232\"><label class=\"quform-label-text\" id=\"quform_6_232_9a10a6_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_232\"><div class=\"quform-input quform-input-radio quform-input-6_232 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_232_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_232\" id=\"quform_6_232_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_232 quform-field-6_232_2\" value=\"Si\" \/><label for=\"quform_6_232_9a10a6_2\" class=\"quform-option-label quform-option-label-6_232_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_232\" id=\"quform_6_232_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_232 quform-field-6_232_1\" value=\"No\" \/><label for=\"quform_6_232_9a10a6_1\" class=\"quform-option-label quform-option-label-6_232_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_233 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_233\"><label class=\"quform-label-text\" for=\"quform_6_233_9a10a6\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_233\"><div class=\"quform-input quform-input-text quform-input-6_233 quform-cf\"><input type=\"text\" id=\"quform_6_233_9a10a6\" name=\"quform_6_233\" class=\"quform-field quform-field-text quform-field-6_233\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_234 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_234\"><label class=\"quform-label-text\" id=\"quform_6_234_9a10a6_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_234\"><div class=\"quform-input quform-input-radio quform-input-6_234 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_234_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_234\" id=\"quform_6_234_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_234 quform-field-6_234_2\" value=\"Si\" \/><label for=\"quform_6_234_9a10a6_2\" class=\"quform-option-label quform-option-label-6_234_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_234\" id=\"quform_6_234_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_234 quform-field-6_234_1\" value=\"No\" \/><label for=\"quform_6_234_9a10a6_1\" class=\"quform-option-label quform-option-label-6_234_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_235 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_235\"><label class=\"quform-label-text\" for=\"quform_6_235_9a10a6\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_235\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-6_235 quform-cf\"><textarea id=\"quform_6_235_9a10a6\" name=\"quform_6_235\" class=\"quform-field quform-field-textarea quform-field-6_235\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_236 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_236\"><label class=\"quform-label-text\" for=\"quform_6_236_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_236\"><div class=\"quform-input quform-input-textarea quform-input-6_236 quform-cf\"><textarea id=\"quform_6_236_9a10a6\" name=\"quform_6_236\" class=\"quform-field quform-field-textarea quform-field-6_236\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_221 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_221\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_221\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-237 quform-page-6_237 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_238 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario consulta Fisioterapia Respiratoria (FR)<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_239 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_239\"><label class=\"quform-label-text\" id=\"quform_6_239_9a10a6_label\">Motivo o diagn\u00f3stico por el cual se le ha indicado la Fisioterapia Respiratoria:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_239\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_239 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_239_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_1\" value=\"Incapacidad para toser\" \/><label for=\"quform_6_239_9a10a6_1\" class=\"quform-option-label quform-option-label-6_239_1\"><span class=\"quform-option-text\">Incapacidad para toser<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_2\" value=\"Fibrosis pulmonar\" \/><label for=\"quform_6_239_9a10a6_2\" class=\"quform-option-label quform-option-label-6_239_2\"><span class=\"quform-option-text\">Fibrosis pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_4\" value=\"Enfisema\" \/><label for=\"quform_6_239_9a10a6_4\" class=\"quform-option-label quform-option-label-6_239_4\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_5\" value=\"Neumon\u00eda\" \/><label for=\"quform_6_239_9a10a6_5\" class=\"quform-option-label quform-option-label-6_239_5\"><span class=\"quform-option-text\">Neumon\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_6\" value=\"Neumectom\u00eda\" \/><label for=\"quform_6_239_9a10a6_6\" class=\"quform-option-label quform-option-label-6_239_6\"><span class=\"quform-option-text\">Neumectom\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_7\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC) exacerbado\" \/><label for=\"quform_6_239_9a10a6_7\" class=\"quform-option-label quform-option-label-6_239_7\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC) exacerbado<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_8\" value=\"Asma Bronquial\" \/><label for=\"quform_6_239_9a10a6_8\" class=\"quform-option-label quform-option-label-6_239_8\"><span class=\"quform-option-text\">Asma Bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_9\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_9\" value=\"Neumot\u00f3rax\" \/><label for=\"quform_6_239_9a10a6_9\" class=\"quform-option-label quform-option-label-6_239_9\"><span class=\"quform-option-text\">Neumot\u00f3rax<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_10\" value=\"Obstrucci\u00f3n bronquial\" \/><label for=\"quform_6_239_9a10a6_10\" class=\"quform-option-label quform-option-label-6_239_10\"><span class=\"quform-option-text\">Obstrucci\u00f3n bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_11\" value=\"Bronquitis\" \/><label for=\"quform_6_239_9a10a6_11\" class=\"quform-option-label quform-option-label-6_239_11\"><span class=\"quform-option-text\">Bronquitis<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_12\" value=\"Bronquiectasia\" \/><label for=\"quform_6_239_9a10a6_12\" class=\"quform-option-label quform-option-label-6_239_12\"><span class=\"quform-option-text\">Bronquiectasia<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_13\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_13\" value=\"Pacientes ventilados\" \/><label for=\"quform_6_239_9a10a6_13\" class=\"quform-option-label quform-option-label-6_239_13\"><span class=\"quform-option-text\">Pacientes ventilados<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_15\" value=\"Esclerosis Lateral Amiotr\u00f3fica (ELA)\" \/><label for=\"quform_6_239_9a10a6_15\" class=\"quform-option-label quform-option-label-6_239_15\"><span class=\"quform-option-text\">Esclerosis Lateral Amiotr\u00f3fica (ELA)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_16\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_16\" value=\"Esclerosis m\u00faltiple\" \/><label for=\"quform_6_239_9a10a6_16\" class=\"quform-option-label quform-option-label-6_239_16\"><span class=\"quform-option-text\">Esclerosis m\u00faltiple<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_17\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_17\" value=\"Miastenia gravis\" \/><label for=\"quform_6_239_9a10a6_17\" class=\"quform-option-label quform-option-label-6_239_17\"><span class=\"quform-option-text\">Miastenia gravis<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_18\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_18\" value=\"S\u00edndrome de Guillain-Barre\" \/><label for=\"quform_6_239_9a10a6_18\" class=\"quform-option-label quform-option-label-6_239_18\"><span class=\"quform-option-text\">S\u00edndrome de Guillain-Barre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_25\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_25\" value=\"Enfisema\" \/><label for=\"quform_6_239_9a10a6_25\" class=\"quform-option-label quform-option-label-6_239_25\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_19\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_19\" value=\"Fibrosis qu\u00edstica\" \/><label for=\"quform_6_239_9a10a6_19\" class=\"quform-option-label quform-option-label-6_239_19\"><span class=\"quform-option-text\">Fibrosis qu\u00edstica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_20\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_20\" value=\"Poliomielitis \" \/><label for=\"quform_6_239_9a10a6_20\" class=\"quform-option-label quform-option-label-6_239_20\"><span class=\"quform-option-text\">Poliomielitis <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_21\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_21\" value=\"Distrofia muscular\" \/><label for=\"quform_6_239_9a10a6_21\" class=\"quform-option-label quform-option-label-6_239_21\"><span class=\"quform-option-text\">Distrofia muscular<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_22\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_22\" value=\"Atrofia muscular espinal \" \/><label for=\"quform_6_239_9a10a6_22\" class=\"quform-option-label quform-option-label-6_239_22\"><span class=\"quform-option-text\">Atrofia muscular espinal <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_23\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_23\" value=\"Derrame pleural\" \/><label for=\"quform_6_239_9a10a6_23\" class=\"quform-option-label quform-option-label-6_239_23\"><span class=\"quform-option-text\">Derrame pleural<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_239[]\" id=\"quform_6_239_9a10a6_24\" class=\"quform-field quform-field-checkbox quform-field-6_239 quform-field-6_239_24\" value=\"Edema pulmonar\" \/><label for=\"quform_6_239_9a10a6_24\" class=\"quform-option-label quform-option-label-6_239_24\"><span class=\"quform-option-text\">Edema pulmonar<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_243 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_243\"><label class=\"quform-label-text\" id=\"quform_6_243_9a10a6_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_243\"><div class=\"quform-input quform-input-radio quform-input-6_243 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_243_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_243\" id=\"quform_6_243_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_243 quform-field-6_243_1\" value=\"No\" \/><label for=\"quform_6_243_9a10a6_1\" class=\"quform-option-label quform-option-label-6_243_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_243\" id=\"quform_6_243_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_243 quform-field-6_243_2\" value=\"Si\" \/><label for=\"quform_6_243_9a10a6_2\" class=\"quform-option-label quform-option-label-6_243_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_346 quform-cf\"><div class=\"quform-spacer\"><h4>Antecedentes personales<\/h4><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_244 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_244\"><label class=\"quform-label-text\" for=\"quform_6_244_9a10a6\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_244\"><div class=\"quform-input quform-input-text quform-input-6_244 quform-cf\"><input type=\"text\" id=\"quform_6_244_9a10a6\" name=\"quform_6_244\" class=\"quform-field quform-field-text quform-field-6_244\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_245 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_245\"><label class=\"quform-label-text\" id=\"quform_6_245_9a10a6_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_245\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_245 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_245_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_1\" value=\"Obesidad\" \/><label for=\"quform_6_245_9a10a6_1\" class=\"quform-option-label quform-option-label-6_245_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_245_9a10a6_2\" class=\"quform-option-label quform-option-label-6_245_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_245_9a10a6_4\" class=\"quform-option-label quform-option-label-6_245_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_245_9a10a6_5\" class=\"quform-option-label quform-option-label-6_245_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_245_9a10a6_11\" class=\"quform-option-label quform-option-label-6_245_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_245_9a10a6_6\" class=\"quform-option-label quform-option-label-6_245_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_245_9a10a6_8\" class=\"quform-option-label quform-option-label-6_245_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_245_9a10a6_10\" class=\"quform-option-label quform-option-label-6_245_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_245_9a10a6_15\" class=\"quform-option-label quform-option-label-6_245_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_245_9a10a6_12\" class=\"quform-option-label quform-option-label-6_245_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_245[]\" id=\"quform_6_245_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_245 quform-field-6_245_14\" value=\"Otros\" \/><label for=\"quform_6_245_9a10a6_14\" class=\"quform-option-label quform-option-label-6_245_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_246 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_246\"><label class=\"quform-label-text\" for=\"quform_6_246_9a10a6\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_246\"><div class=\"quform-input quform-input-textarea quform-input-6_246 quform-cf\"><textarea id=\"quform_6_246_9a10a6\" name=\"quform_6_246\" class=\"quform-field quform-field-textarea quform-field-6_246\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_247 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_248 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_248\"><label class=\"quform-label-text\" id=\"quform_6_248_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_248\"><div class=\"quform-input quform-input-radio quform-input-6_248 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_248_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_248\" id=\"quform_6_248_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_248 quform-field-6_248_2\" value=\"Si\" \/><label for=\"quform_6_248_9a10a6_2\" class=\"quform-option-label quform-option-label-6_248_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_248\" id=\"quform_6_248_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_248 quform-field-6_248_1\" value=\"No\" \/><label for=\"quform_6_248_9a10a6_1\" class=\"quform-option-label quform-option-label-6_248_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_248\" id=\"quform_6_248_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_248 quform-field-6_248_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_6_248_9a10a6_4\" class=\"quform-option-label quform-option-label-6_248_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_347 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_347\"><label class=\"quform-label-text\" for=\"quform_6_347_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_347\"><div class=\"quform-input quform-input-text quform-input-6_347 quform-cf\"><input type=\"text\" id=\"quform_6_347_9a10a6\" name=\"quform_6_347\" class=\"quform-field quform-field-text quform-field-6_347\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_249 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_249\"><label class=\"quform-label-text\" id=\"quform_6_249_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_249\"><div class=\"quform-input quform-input-radio quform-input-6_249 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_249_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_249\" id=\"quform_6_249_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_249 quform-field-6_249_2\" value=\"Si\" \/><label for=\"quform_6_249_9a10a6_2\" class=\"quform-option-label quform-option-label-6_249_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_249\" id=\"quform_6_249_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_249 quform-field-6_249_1\" value=\"No\" \/><label for=\"quform_6_249_9a10a6_1\" class=\"quform-option-label quform-option-label-6_249_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_348 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_348\"><label class=\"quform-label-text\" for=\"quform_6_348_9a10a6\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_348\"><div class=\"quform-input quform-input-text quform-input-6_348 quform-cf\"><input type=\"text\" id=\"quform_6_348_9a10a6\" name=\"quform_6_348\" class=\"quform-field quform-field-text quform-field-6_348\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_250 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_250\"><label class=\"quform-label-text\" id=\"quform_6_250_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_250\"><div class=\"quform-input quform-input-radio quform-input-6_250 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_250_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_250\" id=\"quform_6_250_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_250 quform-field-6_250_2\" value=\"Si\" \/><label for=\"quform_6_250_9a10a6_2\" class=\"quform-option-label quform-option-label-6_250_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_250\" id=\"quform_6_250_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_250 quform-field-6_250_1\" value=\"No\" \/><label for=\"quform_6_250_9a10a6_1\" class=\"quform-option-label quform-option-label-6_250_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_251 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_251\"><label class=\"quform-label-text\" id=\"quform_6_251_9a10a6_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_251\"><div class=\"quform-input quform-input-radio quform-input-6_251 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_251_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_251\" id=\"quform_6_251_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_251 quform-field-6_251_2\" value=\"Si\" \/><label for=\"quform_6_251_9a10a6_2\" class=\"quform-option-label quform-option-label-6_251_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_251\" id=\"quform_6_251_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_251 quform-field-6_251_1\" value=\"No\" \/><label for=\"quform_6_251_9a10a6_1\" class=\"quform-option-label quform-option-label-6_251_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_252 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_252\"><label class=\"quform-label-text\" for=\"quform_6_252_9a10a6\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_252\"><div class=\"quform-input quform-input-text quform-input-6_252 quform-cf\"><input type=\"text\" id=\"quform_6_252_9a10a6\" name=\"quform_6_252\" class=\"quform-field quform-field-text quform-field-6_252\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_253 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_253\"><label class=\"quform-label-text\" id=\"quform_6_253_9a10a6_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_253\"><div class=\"quform-input quform-input-radio quform-input-6_253 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_253_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_253\" id=\"quform_6_253_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_253 quform-field-6_253_2\" value=\"Si\" \/><label for=\"quform_6_253_9a10a6_2\" class=\"quform-option-label quform-option-label-6_253_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_253\" id=\"quform_6_253_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_253 quform-field-6_253_1\" value=\"No\" \/><label for=\"quform_6_253_9a10a6_1\" class=\"quform-option-label quform-option-label-6_253_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_254 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_254\"><label class=\"quform-label-text\" for=\"quform_6_254_9a10a6\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_254\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-6_254 quform-cf\"><textarea id=\"quform_6_254_9a10a6\" name=\"quform_6_254\" class=\"quform-field quform-field-textarea quform-field-6_254\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_255 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_255\"><label class=\"quform-label-text\" for=\"quform_6_255_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_255\"><div class=\"quform-input quform-input-textarea quform-input-6_255 quform-cf\"><textarea id=\"quform_6_255_9a10a6\" name=\"quform_6_255\" class=\"quform-field quform-field-textarea quform-field-6_255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_256 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_256\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_256\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-257 quform-page-6_257 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_258 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario consulta VIDAIR Bienestar Nutricional\u00ae:  sensibilidad alimentaria - microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico. <\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_259 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_259\"><label class=\"quform-label-text\" id=\"quform_6_259_9a10a6_label\">Motivo de consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_259\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_259 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_259_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_1\" value=\"Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Bajo peso.\" \/><label for=\"quform_6_259_9a10a6_1\" class=\"quform-option-label quform-option-label-6_259_1\"><span class=\"quform-option-text\">Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Bajo peso.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_2\" value=\"Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas. \" \/><label for=\"quform_6_259_9a10a6_2\" class=\"quform-option-label quform-option-label-6_259_2\"><span class=\"quform-option-text\">Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_4\" value=\"Sistema nervioso: Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza.\" \/><label for=\"quform_6_259_9a10a6_4\" class=\"quform-option-label quform-option-label-6_259_4\"><span class=\"quform-option-text\">Sistema nervioso: Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_5\" value=\"Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes.\" \/><label for=\"quform_6_259_9a10a6_5\" class=\"quform-option-label quform-option-label-6_259_5\"><span class=\"quform-option-text\">Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_6\" value=\"Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.\" \/><label for=\"quform_6_259_9a10a6_6\" class=\"quform-option-label quform-option-label-6_259_6\"><span class=\"quform-option-text\">Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_259[]\" id=\"quform_6_259_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_259 quform-field-6_259_7\" value=\"Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. Fibromialgia. Otras enfermedades autoinmunes. \" \/><label for=\"quform_6_259_9a10a6_7\" class=\"quform-option-label quform-option-label-6_259_7\"><span class=\"quform-option-text\">Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. Fibromialgia. Otras enfermedades autoinmunes. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_274 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_274\"><label class=\"quform-label-text\" id=\"quform_6_274_9a10a6_label\">Antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_274\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_274 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_274_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_1\" value=\"Obesidad\" \/><label for=\"quform_6_274_9a10a6_1\" class=\"quform-option-label quform-option-label-6_274_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_274_9a10a6_2\" class=\"quform-option-label quform-option-label-6_274_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_274_9a10a6_4\" class=\"quform-option-label quform-option-label-6_274_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_274_9a10a6_11\" class=\"quform-option-label quform-option-label-6_274_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_274_9a10a6_5\" class=\"quform-option-label quform-option-label-6_274_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_274_9a10a6_6\" class=\"quform-option-label quform-option-label-6_274_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_16\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_16\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_6_274_9a10a6_16\" class=\"quform-option-label quform-option-label-6_274_16\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_17\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_17\" value=\"Enfisema\" \/><label for=\"quform_6_274_9a10a6_17\" class=\"quform-option-label quform-option-label-6_274_17\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_274_9a10a6_8\" class=\"quform-option-label quform-option-label-6_274_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_274_9a10a6_10\" class=\"quform-option-label quform-option-label-6_274_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_274_9a10a6_15\" class=\"quform-option-label quform-option-label-6_274_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_274_9a10a6_12\" class=\"quform-option-label quform-option-label-6_274_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_274[]\" id=\"quform_6_274_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_274 quform-field-6_274_14\" value=\"Otros\" \/><label for=\"quform_6_274_9a10a6_14\" class=\"quform-option-label quform-option-label-6_274_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_263 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_263\"><label class=\"quform-label-text\" for=\"quform_6_263_9a10a6\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_263\"><div class=\"quform-input quform-input-textarea quform-input-6_263 quform-cf\"><textarea id=\"quform_6_263_9a10a6\" name=\"quform_6_263\" class=\"quform-field quform-field-textarea quform-field-6_263\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_260 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_260\"><label class=\"quform-label-text\" id=\"quform_6_260_9a10a6_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_260\"><div class=\"quform-input quform-input-radio quform-input-6_260 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_260_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_260\" id=\"quform_6_260_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_260 quform-field-6_260_1\" value=\"No\" \/><label for=\"quform_6_260_9a10a6_1\" class=\"quform-option-label quform-option-label-6_260_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_260\" id=\"quform_6_260_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_260 quform-field-6_260_2\" value=\"Si\" \/><label for=\"quform_6_260_9a10a6_2\" class=\"quform-option-label quform-option-label-6_260_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_261 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_261\"><label class=\"quform-label-text\" for=\"quform_6_261_9a10a6\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_261\"><div class=\"quform-input quform-input-text quform-input-6_261 quform-cf\"><input type=\"text\" id=\"quform_6_261_9a10a6\" name=\"quform_6_261\" class=\"quform-field quform-field-text quform-field-6_261\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_262 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_262\"><label class=\"quform-label-text\" id=\"quform_6_262_9a10a6_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_262\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_262 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_262_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_1\" value=\"Obesidad\" \/><label for=\"quform_6_262_9a10a6_1\" class=\"quform-option-label quform-option-label-6_262_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_262_9a10a6_2\" class=\"quform-option-label quform-option-label-6_262_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_262_9a10a6_4\" class=\"quform-option-label quform-option-label-6_262_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_262_9a10a6_5\" class=\"quform-option-label quform-option-label-6_262_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_262_9a10a6_11\" class=\"quform-option-label quform-option-label-6_262_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_262_9a10a6_6\" class=\"quform-option-label quform-option-label-6_262_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_262_9a10a6_8\" class=\"quform-option-label quform-option-label-6_262_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_262_9a10a6_10\" class=\"quform-option-label quform-option-label-6_262_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_262_9a10a6_15\" class=\"quform-option-label quform-option-label-6_262_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_262_9a10a6_12\" class=\"quform-option-label quform-option-label-6_262_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_262[]\" id=\"quform_6_262_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_262 quform-field-6_262_14\" value=\"Otros\" \/><label for=\"quform_6_262_9a10a6_14\" class=\"quform-option-label quform-option-label-6_262_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_275 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_275\"><label class=\"quform-label-text\" for=\"quform_6_275_9a10a6\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_275\"><div class=\"quform-input quform-input-textarea quform-input-6_275 quform-cf\"><textarea id=\"quform_6_275_9a10a6\" name=\"quform_6_275\" class=\"quform-field quform-field-textarea quform-field-6_275\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_264 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_265 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_265\"><label class=\"quform-label-text\" id=\"quform_6_265_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_265\"><div class=\"quform-input quform-input-radio quform-input-6_265 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_265_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_265\" id=\"quform_6_265_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_265 quform-field-6_265_2\" value=\"Si\" \/><label for=\"quform_6_265_9a10a6_2\" class=\"quform-option-label quform-option-label-6_265_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_265\" id=\"quform_6_265_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_265 quform-field-6_265_1\" value=\"No\" \/><label for=\"quform_6_265_9a10a6_1\" class=\"quform-option-label quform-option-label-6_265_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_265\" id=\"quform_6_265_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_265 quform-field-6_265_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_6_265_9a10a6_4\" class=\"quform-option-label quform-option-label-6_265_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_349 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_349\"><label class=\"quform-label-text\" for=\"quform_6_349_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_349\"><div class=\"quform-input quform-input-text quform-input-6_349 quform-cf\"><input type=\"text\" id=\"quform_6_349_9a10a6\" name=\"quform_6_349\" class=\"quform-field quform-field-text quform-field-6_349\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_266 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_266\"><label class=\"quform-label-text\" id=\"quform_6_266_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_266\"><div class=\"quform-input quform-input-radio quform-input-6_266 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_266_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_266\" id=\"quform_6_266_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_266 quform-field-6_266_2\" value=\"Si\" \/><label for=\"quform_6_266_9a10a6_2\" class=\"quform-option-label quform-option-label-6_266_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_266\" id=\"quform_6_266_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_266 quform-field-6_266_1\" value=\"No\" \/><label for=\"quform_6_266_9a10a6_1\" class=\"quform-option-label quform-option-label-6_266_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_350 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_350\"><label class=\"quform-label-text\" for=\"quform_6_350_9a10a6\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_350\"><div class=\"quform-input quform-input-text quform-input-6_350 quform-cf\"><input type=\"text\" id=\"quform_6_350_9a10a6\" name=\"quform_6_350\" class=\"quform-field quform-field-text quform-field-6_350\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_267 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_267\"><label class=\"quform-label-text\" id=\"quform_6_267_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_267\"><div class=\"quform-input quform-input-radio quform-input-6_267 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_267_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_267\" id=\"quform_6_267_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_267 quform-field-6_267_2\" value=\"Si\" \/><label for=\"quform_6_267_9a10a6_2\" class=\"quform-option-label quform-option-label-6_267_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_267\" id=\"quform_6_267_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_267 quform-field-6_267_1\" value=\"No\" \/><label for=\"quform_6_267_9a10a6_1\" class=\"quform-option-label quform-option-label-6_267_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_268 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_268\"><label class=\"quform-label-text\" id=\"quform_6_268_9a10a6_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_268\"><div class=\"quform-input quform-input-radio quform-input-6_268 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_268_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_268\" id=\"quform_6_268_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_268 quform-field-6_268_2\" value=\"Si\" \/><label for=\"quform_6_268_9a10a6_2\" class=\"quform-option-label quform-option-label-6_268_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_268\" id=\"quform_6_268_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_268 quform-field-6_268_1\" value=\"No\" \/><label for=\"quform_6_268_9a10a6_1\" class=\"quform-option-label quform-option-label-6_268_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_269 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_269\"><label class=\"quform-label-text\" for=\"quform_6_269_9a10a6\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_269\"><div class=\"quform-input quform-input-text quform-input-6_269 quform-cf\"><input type=\"text\" id=\"quform_6_269_9a10a6\" name=\"quform_6_269\" class=\"quform-field quform-field-text quform-field-6_269\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_270 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_270\"><label class=\"quform-label-text\" id=\"quform_6_270_9a10a6_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_270\"><div class=\"quform-input quform-input-radio quform-input-6_270 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_270_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_270\" id=\"quform_6_270_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_270 quform-field-6_270_2\" value=\"Si\" \/><label for=\"quform_6_270_9a10a6_2\" class=\"quform-option-label quform-option-label-6_270_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_270\" id=\"quform_6_270_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_270 quform-field-6_270_1\" value=\"No\" \/><label for=\"quform_6_270_9a10a6_1\" class=\"quform-option-label quform-option-label-6_270_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_271 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_271\"><label class=\"quform-label-text\" for=\"quform_6_271_9a10a6\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_271\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-6_271 quform-cf\"><textarea id=\"quform_6_271_9a10a6\" name=\"quform_6_271\" class=\"quform-field quform-field-textarea quform-field-6_271\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_272 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_272\"><label class=\"quform-label-text\" for=\"quform_6_272_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_272\"><div class=\"quform-input quform-input-textarea quform-input-6_272 quform-cf\"><textarea id=\"quform_6_272_9a10a6\" name=\"quform_6_272\" class=\"quform-field quform-field-textarea quform-field-6_272\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_273 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_273\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_273\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-276 quform-page-6_276 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_277 quform-cf\"><div class=\"quform-spacer\"><h3>CUESTIONARIOS PARA ESTUDIOS Y PRUEBAS DIAGN\u00d3STICAS<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_278 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_278\"><label class=\"quform-label-text\" id=\"quform_6_278_9a10a6_label\">Seleccione la prueba diagn\u00f3stica que desea realizar en VIDAIR<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_278\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_278 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_278_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_1\" value=\"Polisomnograf\u00eda (PSG)\" \/><label for=\"quform_6_278_9a10a6_1\" class=\"quform-option-label quform-option-label-6_278_1\"><span class=\"quform-option-text\">Polisomnograf\u00eda (PSG)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_2\" value=\"Poligrafia respiratoria (PL)\" \/><label for=\"quform_6_278_9a10a6_2\" class=\"quform-option-label quform-option-label-6_278_2\"><span class=\"quform-option-text\">Poligrafia respiratoria (PL)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_4\" value=\"Capnograf\u00eda\" \/><label for=\"quform_6_278_9a10a6_4\" class=\"quform-option-label quform-option-label-6_278_4\"><span class=\"quform-option-text\">Capnograf\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_5\" value=\"Test de marcha de 6 minutos \" \/><label for=\"quform_6_278_9a10a6_5\" class=\"quform-option-label quform-option-label-6_278_5\"><span class=\"quform-option-text\">Test de marcha de 6 minutos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_6\" value=\"Espirometr\u00eda con test de broncodilataci\u00f3n \" \/><label for=\"quform_6_278_9a10a6_6\" class=\"quform-option-label quform-option-label-6_278_6\"><span class=\"quform-option-text\">Espirometr\u00eda con test de broncodilataci\u00f3n <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_7\" value=\"Titulaci\u00f3n y\/o monitorizaci\u00f3n con CPAP\" \/><label for=\"quform_6_278_9a10a6_7\" class=\"quform-option-label quform-option-label-6_278_7\"><span class=\"quform-option-text\">Titulaci\u00f3n y\/o monitorizaci\u00f3n con CPAP<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_25\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_25\" value=\"Pulsioximetr\u00eda\" \/><label for=\"quform_6_278_9a10a6_25\" class=\"quform-option-label quform-option-label-6_278_25\"><span class=\"quform-option-text\">Pulsioximetr\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_26\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_26\" value=\"Prueba de sensibilidad alimentaria\" \/><label for=\"quform_6_278_9a10a6_26\" class=\"quform-option-label quform-option-label-6_278_26\"><span class=\"quform-option-text\">Prueba de sensibilidad alimentaria<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_278[]\" id=\"quform_6_278_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_278 quform-field-6_278_27\" value=\"Laboratorio de nutrici\u00f3n y epigen\u00e9tica\" \/><label for=\"quform_6_278_9a10a6_27\" class=\"quform-option-label quform-option-label-6_278_27\"><span class=\"quform-option-text\">Laboratorio de nutrici\u00f3n y epigen\u00e9tica<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_296 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_296\"><label class=\"quform-label-text\" id=\"quform_6_296_9a10a6_label\">LABORATORIO NUTRICI\u00d3N y EPIGEN\u00c9TICA<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_296\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_296 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_296_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_1\" value=\"Sensibilidad alimentaria IgG\" \/><label for=\"quform_6_296_9a10a6_1\" class=\"quform-option-label quform-option-label-6_296_1\"><span class=\"quform-option-text\">Sensibilidad alimentaria IgG<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_2\" value=\"Secreci\u00f3n de melatonina\" \/><label for=\"quform_6_296_9a10a6_2\" class=\"quform-option-label quform-option-label-6_296_2\"><span class=\"quform-option-text\">Secreci\u00f3n de melatonina<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_4\" value=\"Alergias alimentarias IgE\" \/><label for=\"quform_6_296_9a10a6_4\" class=\"quform-option-label quform-option-label-6_296_4\"><span class=\"quform-option-text\">Alergias alimentarias IgE<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_5\" value=\"Gen\u00e9tica de gluten \u2013 Gen HLA-DQ cel\u00edaco o celiaqu\u00eda\" \/><label for=\"quform_6_296_9a10a6_5\" class=\"quform-option-label quform-option-label-6_296_5\"><span class=\"quform-option-text\">Gen\u00e9tica de gluten \u2013 Gen HLA-DQ cel\u00edaco o celiaqu\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_6\" value=\"Gastrointestinal (microrganismos pat\u00f3genos, beneficioso, marcadores inflamat\u00f3rios,)\" \/><label for=\"quform_6_296_9a10a6_6\" class=\"quform-option-label quform-option-label-6_296_6\"><span class=\"quform-option-text\">Gastrointestinal (microrganismos pat\u00f3genos, beneficioso, marcadores inflamat\u00f3rios,)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_7\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_7\" value=\" Infecciones (c\u00e1ndida y otros organismos pat\u00f3genos)\" \/><label for=\"quform_6_296_9a10a6_7\" class=\"quform-option-label quform-option-label-6_296_7\"><span class=\"quform-option-text\"> Infecciones (c\u00e1ndida y otros organismos pat\u00f3genos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_25\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_25\" value=\"\u00c1cidos org\u00e1nicos (mide deficiencia de detoxificaci\u00f3n, antioxidantes y microorganismos)\" \/><label for=\"quform_6_296_9a10a6_25\" class=\"quform-option-label quform-option-label-6_296_25\"><span class=\"quform-option-text\">\u00c1cidos org\u00e1nicos (mide deficiencia de detoxificaci\u00f3n, antioxidantes y microorganismos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_26\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_26\" value=\"Metales pesados (presencia y toxicidad por metales pesados en el organismo.\" \/><label for=\"quform_6_296_9a10a6_26\" class=\"quform-option-label quform-option-label-6_296_26\"><span class=\"quform-option-text\">Metales pesados (presencia y toxicidad por metales pesados en el organismo.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_27\" value=\"Vitaminas y minerales ( mide micronutrientes a nivel celular, que es m\u00e1s efectivo que a nivel  sangu\u00edneo)\" \/><label for=\"quform_6_296_9a10a6_27\" class=\"quform-option-label quform-option-label-6_296_27\"><span class=\"quform-option-text\">Vitaminas y minerales ( mide micronutrientes a nivel celular, que es m\u00e1s efectivo que a nivel  sangu\u00edneo)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_28\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_28\" value=\"Epigen\u00e9tica (variaciones gen\u00e9ticas que influyen en la salud o enfermedad, incluyendo la  metilaci\u00f3n)\" \/><label for=\"quform_6_296_9a10a6_28\" class=\"quform-option-label quform-option-label-6_296_28\"><span class=\"quform-option-text\">Epigen\u00e9tica (variaciones gen\u00e9ticas que influyen en la salud o enfermedad, incluyendo la  metilaci\u00f3n)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_29\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_29\" value=\"Hormonas (an\u00e1lisis de hormonas adrenales y sexuales)\" \/><label for=\"quform_6_296_9a10a6_29\" class=\"quform-option-label quform-option-label-6_296_29\"><span class=\"quform-option-text\">Hormonas (an\u00e1lisis de hormonas adrenales y sexuales)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_30\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_30\" value=\"Neurotransmisores (neurotransmisores que influyen en el comportamiento humano)\" \/><label for=\"quform_6_296_9a10a6_30\" class=\"quform-option-label quform-option-label-6_296_30\"><span class=\"quform-option-text\">Neurotransmisores (neurotransmisores que influyen en el comportamiento humano)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_296[]\" id=\"quform_6_296_9a10a6_31\" class=\"quform-field quform-field-checkbox quform-field-6_296 quform-field-6_296_31\" value=\"PANDAS (pedi\u00e1trico, neuropsiqui\u00e1trico associado com Streptococcus)\" \/><label for=\"quform_6_296_9a10a6_31\" class=\"quform-option-label quform-option-label-6_296_31\"><span class=\"quform-option-text\">PANDAS (pedi\u00e1trico, neuropsiqui\u00e1trico associado com Streptococcus)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_297 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_297\"><label class=\"quform-label-text\" id=\"quform_6_297_9a10a6_label\"><b>Espirometr\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_297\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_297 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_297_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_1\" value=\"Asma bronquial\" \/><label for=\"quform_6_297_9a10a6_1\" class=\"quform-option-label quform-option-label-6_297_1\"><span class=\"quform-option-text\">Asma bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_2\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC)\" \/><label for=\"quform_6_297_9a10a6_2\" class=\"quform-option-label quform-option-label-6_297_2\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_4\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_6_297_9a10a6_4\" class=\"quform-option-label quform-option-label-6_297_4\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_5\" value=\"Enfisema\" \/><label for=\"quform_6_297_9a10a6_5\" class=\"quform-option-label quform-option-label-6_297_5\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_6\" value=\"Fibrosis pulmonar\" \/><label for=\"quform_6_297_9a10a6_6\" class=\"quform-option-label quform-option-label-6_297_6\"><span class=\"quform-option-text\">Fibrosis pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_297[]\" id=\"quform_6_297_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_297 quform-field-6_297_27\" value=\"Otros\" \/><label for=\"quform_6_297_9a10a6_27\" class=\"quform-option-label quform-option-label-6_297_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_282 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_282\"><label class=\"quform-label-text\" for=\"quform_6_282_9a10a6\">Enumere el resto de motivos por los que se le ha indicado realizar una Espirometr\u00eda<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_282\"><div class=\"quform-input quform-input-text quform-input-6_282 quform-cf\"><input type=\"text\" id=\"quform_6_282_9a10a6\" name=\"quform_6_282\" class=\"quform-field quform-field-text quform-field-6_282\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_300 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_300\"><label class=\"quform-label-text\" id=\"quform_6_300_9a10a6_label\"><b>Polisomnograf\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_300\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_300 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_300_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_1\" value=\"Apnea Obstructiva del Sue\u00f1o (AOS)\" \/><label for=\"quform_6_300_9a10a6_1\" class=\"quform-option-label quform-option-label-6_300_1\"><span class=\"quform-option-text\">Apnea Obstructiva del Sue\u00f1o (AOS)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_2\" value=\"S\u00edndrome de movimientos peri\u00f3dicos de las piernas\" \/><label for=\"quform_6_300_9a10a6_2\" class=\"quform-option-label quform-option-label-6_300_2\"><span class=\"quform-option-text\">S\u00edndrome de movimientos peri\u00f3dicos de las piernas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_4\" value=\"Narcolepsia \" \/><label for=\"quform_6_300_9a10a6_4\" class=\"quform-option-label quform-option-label-6_300_4\"><span class=\"quform-option-text\">Narcolepsia <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_5\" value=\"Conductas inusuales durante el sue\u00f1o\" \/><label for=\"quform_6_300_9a10a6_5\" class=\"quform-option-label quform-option-label-6_300_5\"><span class=\"quform-option-text\">Conductas inusuales durante el sue\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_6\" value=\"Insomnio cr\u00f3nico sin causa aparente\" \/><label for=\"quform_6_300_9a10a6_6\" class=\"quform-option-label quform-option-label-6_300_6\"><span class=\"quform-option-text\">Insomnio cr\u00f3nico sin causa aparente<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_28\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_28\" value=\"Trastorno de conducta del sue\u00f1o con movimientos oculares r\u00e1pidos\" \/><label for=\"quform_6_300_9a10a6_28\" class=\"quform-option-label quform-option-label-6_300_28\"><span class=\"quform-option-text\">Trastorno de conducta del sue\u00f1o con movimientos oculares r\u00e1pidos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_300[]\" id=\"quform_6_300_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_300 quform-field-6_300_27\" value=\"Otros\" \/><label for=\"quform_6_300_9a10a6_27\" class=\"quform-option-label quform-option-label-6_300_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_301 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_301\"><label class=\"quform-label-text\" for=\"quform_6_301_9a10a6\">Enumere el resto de motivos por los que se le ha indicado realizar una Polisomnograf\u00eda <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_301\"><div class=\"quform-input quform-input-text quform-input-6_301 quform-cf\"><input type=\"text\" id=\"quform_6_301_9a10a6\" name=\"quform_6_301\" class=\"quform-field quform-field-text quform-field-6_301\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_302 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_302\"><label class=\"quform-label-text\" id=\"quform_6_302_9a10a6_label\"><b>Poligrafia Respiratoria<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_302\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_302 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_302_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_302[]\" id=\"quform_6_302_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_302 quform-field-6_302_1\" value=\"Ronquidos. Sospecha Apnea Obstructiva del sue\u00f1o (AOS)\" \/><label for=\"quform_6_302_9a10a6_1\" class=\"quform-option-label quform-option-label-6_302_1\"><span class=\"quform-option-text\">Ronquidos. Sospecha Apnea Obstructiva del sue\u00f1o (AOS)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_302[]\" id=\"quform_6_302_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_302 quform-field-6_302_27\" value=\"Otros\" \/><label for=\"quform_6_302_9a10a6_27\" class=\"quform-option-label quform-option-label-6_302_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_303 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_303\"><label class=\"quform-label-text\" for=\"quform_6_303_9a10a6\">Enumere el resto de motivos por los que se le ha indicado realizar una Poligrafia Respiratoria<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_303\"><div class=\"quform-input quform-input-text quform-input-6_303 quform-cf\"><input type=\"text\" id=\"quform_6_303_9a10a6\" name=\"quform_6_303\" class=\"quform-field quform-field-text quform-field-6_303\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_304 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_304\"><label class=\"quform-label-text\" id=\"quform_6_304_9a10a6_label\"><b>Test de marcha de 6 minutos<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_304\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_304 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_304_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_304[]\" id=\"quform_6_304_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_304 quform-field-6_304_1\" value=\"Hipertensi\u00f3n pulmonar\" \/><label for=\"quform_6_304_9a10a6_1\" class=\"quform-option-label quform-option-label-6_304_1\"><span class=\"quform-option-text\">Hipertensi\u00f3n pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_304[]\" id=\"quform_6_304_9a10a6_29\" class=\"quform-field quform-field-checkbox quform-field-6_304 quform-field-6_304_29\" value=\"Insuficiencia cardiaca\" \/><label for=\"quform_6_304_9a10a6_29\" class=\"quform-option-label quform-option-label-6_304_29\"><span class=\"quform-option-text\">Insuficiencia cardiaca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_304[]\" id=\"quform_6_304_9a10a6_30\" class=\"quform-field quform-field-checkbox quform-field-6_304 quform-field-6_304_30\" value=\"Enfermedad Obstructiva Cr\u00f3nica (EPOC)\" \/><label for=\"quform_6_304_9a10a6_30\" class=\"quform-option-label quform-option-label-6_304_30\"><span class=\"quform-option-text\">Enfermedad Obstructiva Cr\u00f3nica (EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_304[]\" id=\"quform_6_304_9a10a6_31\" class=\"quform-field quform-field-checkbox quform-field-6_304 quform-field-6_304_31\" value=\"Fibrosis Pulmonar \" \/><label for=\"quform_6_304_9a10a6_31\" class=\"quform-option-label quform-option-label-6_304_31\"><span class=\"quform-option-text\">Fibrosis Pulmonar <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_304[]\" id=\"quform_6_304_9a10a6_27\" class=\"quform-field quform-field-checkbox quform-field-6_304 quform-field-6_304_27\" value=\"Otros\" \/><label for=\"quform_6_304_9a10a6_27\" class=\"quform-option-label quform-option-label-6_304_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_305 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_305\"><label class=\"quform-label-text\" for=\"quform_6_305_9a10a6\">Enumere el resto de motivos por los que se le ha indicado realizar un Test de marcha de 6 minutos <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_305\"><div class=\"quform-input quform-input-text quform-input-6_305 quform-cf\"><input type=\"text\" id=\"quform_6_305_9a10a6\" name=\"quform_6_305\" class=\"quform-field quform-field-text quform-field-6_305\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_306 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_306\"><label class=\"quform-label-text\" id=\"quform_6_306_9a10a6_label\"><b>Pulsioximetr\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_306\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_306 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_306_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_306[]\" id=\"quform_6_306_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_306 quform-field-6_306_1\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica EPOC)\" \/><label for=\"quform_6_306_9a10a6_1\" class=\"quform-option-label quform-option-label-6_306_1\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_306[]\" id=\"quform_6_306_9a10a6_29\" class=\"quform-field quform-field-checkbox quform-field-6_306 quform-field-6_306_29\" value=\"Asma Bronquial \" \/><label for=\"quform_6_306_9a10a6_29\" class=\"quform-option-label quform-option-label-6_306_29\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_306[]\" id=\"quform_6_306_9a10a6_30\" class=\"quform-field quform-field-checkbox quform-field-6_306 quform-field-6_306_30\" value=\"Infecci\u00f3n respiratoria aguda (neumon\u00eda, influenza, infecciones respiratoria relacionada con SIDA)\" \/><label for=\"quform_6_306_9a10a6_30\" class=\"quform-option-label quform-option-label-6_306_30\"><span class=\"quform-option-text\">Infecci\u00f3n respiratoria aguda (neumon\u00eda, influenza, infecciones respiratoria relacionada con SIDA)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_306[]\" id=\"quform_6_306_9a10a6_31\" class=\"quform-field quform-field-checkbox quform-field-6_306 quform-field-6_306_31\" value=\"COVID 19\" \/><label for=\"quform_6_306_9a10a6_31\" class=\"quform-option-label quform-option-label-6_306_31\"><span class=\"quform-option-text\">COVID 19<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_307 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_307\"><label class=\"quform-label-text\" id=\"quform_6_307_9a10a6_label\"><b>Prueba de sensibilidad alimentaria<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_307\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_307 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_307_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_307[]\" id=\"quform_6_307_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_307 quform-field-6_307_1\" value=\"Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas.\" \/><label for=\"quform_6_307_9a10a6_1\" class=\"quform-option-label quform-option-label-6_307_1\"><span class=\"quform-option-text\">Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_307[]\" id=\"quform_6_307_9a10a6_29\" class=\"quform-field quform-field-checkbox quform-field-6_307 quform-field-6_307_29\" value=\"Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes. \" \/><label for=\"quform_6_307_9a10a6_29\" class=\"quform-option-label quform-option-label-6_307_29\"><span class=\"quform-option-text\">Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_307[]\" id=\"quform_6_307_9a10a6_30\" class=\"quform-field quform-field-checkbox quform-field-6_307 quform-field-6_307_30\" value=\"Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.\" \/><label for=\"quform_6_307_9a10a6_30\" class=\"quform-option-label quform-option-label-6_307_30\"><span class=\"quform-option-text\">Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_307[]\" id=\"quform_6_307_9a10a6_32\" class=\"quform-field quform-field-checkbox quform-field-6_307 quform-field-6_307_32\" value=\"Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. \" \/><label for=\"quform_6_307_9a10a6_32\" class=\"quform-option-label quform-option-label-6_307_32\"><span class=\"quform-option-text\">Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_307[]\" id=\"quform_6_307_9a10a6_31\" class=\"quform-field quform-field-checkbox quform-field-6_307 quform-field-6_307_31\" value=\"Otros: Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Fibromialgia. Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza. \" \/><label for=\"quform_6_307_9a10a6_31\" class=\"quform-option-label quform-option-label-6_307_31\"><span class=\"quform-option-text\">Otros: Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Fibromialgia. Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_299 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes personales<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_279 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_279\"><label class=\"quform-label-text\" id=\"quform_6_279_9a10a6_label\">Ha padecido con anterioridad o padece...<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_279\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_279 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_279_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_1\" value=\"Obesidad\" \/><label for=\"quform_6_279_9a10a6_1\" class=\"quform-option-label quform-option-label-6_279_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_279_9a10a6_2\" class=\"quform-option-label quform-option-label-6_279_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_279_9a10a6_4\" class=\"quform-option-label quform-option-label-6_279_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_279_9a10a6_11\" class=\"quform-option-label quform-option-label-6_279_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_279_9a10a6_5\" class=\"quform-option-label quform-option-label-6_279_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_279_9a10a6_6\" class=\"quform-option-label quform-option-label-6_279_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_16\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_16\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_6_279_9a10a6_16\" class=\"quform-option-label quform-option-label-6_279_16\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_17\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_17\" value=\"Enfisema\" \/><label for=\"quform_6_279_9a10a6_17\" class=\"quform-option-label quform-option-label-6_279_17\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_279_9a10a6_8\" class=\"quform-option-label quform-option-label-6_279_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_279_9a10a6_10\" class=\"quform-option-label quform-option-label-6_279_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_279_9a10a6_15\" class=\"quform-option-label quform-option-label-6_279_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_279_9a10a6_12\" class=\"quform-option-label quform-option-label-6_279_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_279[]\" id=\"quform_6_279_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_279 quform-field-6_279_14\" value=\"Otros\" \/><label for=\"quform_6_279_9a10a6_14\" class=\"quform-option-label quform-option-label-6_279_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_280 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_280\"><label class=\"quform-label-text\" for=\"quform_6_280_9a10a6\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_280\"><div class=\"quform-input quform-input-textarea quform-input-6_280 quform-cf\"><textarea id=\"quform_6_280_9a10a6\" name=\"quform_6_280\" class=\"quform-field quform-field-textarea quform-field-6_280\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_281 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_281\"><label class=\"quform-label-text\" id=\"quform_6_281_9a10a6_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_281\"><div class=\"quform-input quform-input-radio quform-input-6_281 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_281_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_281\" id=\"quform_6_281_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_281 quform-field-6_281_1\" value=\"No\" \/><label for=\"quform_6_281_9a10a6_1\" class=\"quform-option-label quform-option-label-6_281_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_281\" id=\"quform_6_281_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_281 quform-field-6_281_2\" value=\"Si\" \/><label for=\"quform_6_281_9a10a6_2\" class=\"quform-option-label quform-option-label-6_281_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_298 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_298\"><label class=\"quform-label-text\" for=\"quform_6_298_9a10a6\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_298\"><div class=\"quform-input quform-input-text quform-input-6_298 quform-cf\"><input type=\"text\" id=\"quform_6_298_9a10a6\" name=\"quform_6_298\" class=\"quform-field quform-field-text quform-field-6_298\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_283 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_283\"><label class=\"quform-label-text\" id=\"quform_6_283_9a10a6_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_283\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_283 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_283_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_1\" value=\"Obesidad\" \/><label for=\"quform_6_283_9a10a6_1\" class=\"quform-option-label quform-option-label-6_283_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_283_9a10a6_2\" class=\"quform-option-label quform-option-label-6_283_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_283_9a10a6_4\" class=\"quform-option-label quform-option-label-6_283_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_283_9a10a6_5\" class=\"quform-option-label quform-option-label-6_283_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_283_9a10a6_11\" class=\"quform-option-label quform-option-label-6_283_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_283_9a10a6_6\" class=\"quform-option-label quform-option-label-6_283_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_283_9a10a6_8\" class=\"quform-option-label quform-option-label-6_283_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_283_9a10a6_10\" class=\"quform-option-label quform-option-label-6_283_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_283_9a10a6_15\" class=\"quform-option-label quform-option-label-6_283_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_283_9a10a6_12\" class=\"quform-option-label quform-option-label-6_283_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_283[]\" id=\"quform_6_283_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_283 quform-field-6_283_14\" value=\"Otros\" \/><label for=\"quform_6_283_9a10a6_14\" class=\"quform-option-label quform-option-label-6_283_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_284 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_284\"><label class=\"quform-label-text\" for=\"quform_6_284_9a10a6\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_284\"><div class=\"quform-input quform-input-textarea quform-input-6_284 quform-cf\"><textarea id=\"quform_6_284_9a10a6\" name=\"quform_6_284\" class=\"quform-field quform-field-textarea quform-field-6_284\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_285 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_286 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_286\"><label class=\"quform-label-text\" id=\"quform_6_286_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_286\"><div class=\"quform-input quform-input-radio quform-input-6_286 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_286_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_286\" id=\"quform_6_286_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_286 quform-field-6_286_2\" value=\"Si\" \/><label for=\"quform_6_286_9a10a6_2\" class=\"quform-option-label quform-option-label-6_286_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_286\" id=\"quform_6_286_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_286 quform-field-6_286_1\" value=\"No\" \/><label for=\"quform_6_286_9a10a6_1\" class=\"quform-option-label quform-option-label-6_286_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_286\" id=\"quform_6_286_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_286 quform-field-6_286_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_6_286_9a10a6_4\" class=\"quform-option-label quform-option-label-6_286_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_351 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_351\"><label class=\"quform-label-text\" for=\"quform_6_351_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_351\"><div class=\"quform-input quform-input-text quform-input-6_351 quform-cf\"><input type=\"text\" id=\"quform_6_351_9a10a6\" name=\"quform_6_351\" class=\"quform-field quform-field-text quform-field-6_351\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_287 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_287\"><label class=\"quform-label-text\" id=\"quform_6_287_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_287\"><div class=\"quform-input quform-input-radio quform-input-6_287 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_287_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_287\" id=\"quform_6_287_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_287 quform-field-6_287_2\" value=\"Si\" \/><label for=\"quform_6_287_9a10a6_2\" class=\"quform-option-label quform-option-label-6_287_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_287\" id=\"quform_6_287_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_287 quform-field-6_287_1\" value=\"No\" \/><label for=\"quform_6_287_9a10a6_1\" class=\"quform-option-label quform-option-label-6_287_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_352 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_352\"><label class=\"quform-label-text\" for=\"quform_6_352_9a10a6\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_352\"><div class=\"quform-input quform-input-text quform-input-6_352 quform-cf\"><input type=\"text\" id=\"quform_6_352_9a10a6\" name=\"quform_6_352\" class=\"quform-field quform-field-text quform-field-6_352\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_288 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_288\"><label class=\"quform-label-text\" id=\"quform_6_288_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_288\"><div class=\"quform-input quform-input-radio quform-input-6_288 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_288_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_288\" id=\"quform_6_288_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_288 quform-field-6_288_2\" value=\"Si\" \/><label for=\"quform_6_288_9a10a6_2\" class=\"quform-option-label quform-option-label-6_288_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_288\" id=\"quform_6_288_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_288 quform-field-6_288_1\" value=\"No\" \/><label for=\"quform_6_288_9a10a6_1\" class=\"quform-option-label quform-option-label-6_288_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_289 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_289\"><label class=\"quform-label-text\" id=\"quform_6_289_9a10a6_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_289\"><div class=\"quform-input quform-input-radio quform-input-6_289 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_289_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_289\" id=\"quform_6_289_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_289 quform-field-6_289_2\" value=\"Si\" \/><label for=\"quform_6_289_9a10a6_2\" class=\"quform-option-label quform-option-label-6_289_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_289\" id=\"quform_6_289_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_289 quform-field-6_289_1\" value=\"No\" \/><label for=\"quform_6_289_9a10a6_1\" class=\"quform-option-label quform-option-label-6_289_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_290 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_290\"><label class=\"quform-label-text\" for=\"quform_6_290_9a10a6\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_290\"><div class=\"quform-input quform-input-text quform-input-6_290 quform-cf\"><input type=\"text\" id=\"quform_6_290_9a10a6\" name=\"quform_6_290\" class=\"quform-field quform-field-text quform-field-6_290\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_291 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_291\"><label class=\"quform-label-text\" id=\"quform_6_291_9a10a6_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_291\"><div class=\"quform-input quform-input-radio quform-input-6_291 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_291_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_291\" id=\"quform_6_291_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_291 quform-field-6_291_2\" value=\"Si\" \/><label for=\"quform_6_291_9a10a6_2\" class=\"quform-option-label quform-option-label-6_291_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_291\" id=\"quform_6_291_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_291 quform-field-6_291_1\" value=\"No\" \/><label for=\"quform_6_291_9a10a6_1\" class=\"quform-option-label quform-option-label-6_291_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_292 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_292\"><label class=\"quform-label-text\" for=\"quform_6_292_9a10a6\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_292\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-6_292 quform-cf\"><textarea id=\"quform_6_292_9a10a6\" name=\"quform_6_292\" class=\"quform-field quform-field-textarea quform-field-6_292\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_293 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_293\"><label class=\"quform-label-text\" for=\"quform_6_293_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_293\"><div class=\"quform-input quform-input-textarea quform-input-6_293 quform-cf\"><textarea id=\"quform_6_293_9a10a6\" name=\"quform_6_293\" class=\"quform-field quform-field-textarea quform-field-6_293\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_294 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_294\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_294\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-308 quform-page-6_308 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_309 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario de consultas para Experto Health Coach<\/h3><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_339 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_339\"><label class=\"quform-label-text\" for=\"quform_6_339_9a10a6\">Motivo o diagn\u00f3stico por el cual desea realizar la sesi\u00f3n<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_339\"><div class=\"quform-input quform-input-textarea quform-input-6_339 quform-cf\"><textarea id=\"quform_6_339_9a10a6\" name=\"quform_6_339\" class=\"quform-field quform-field-textarea quform-field-6_339\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_322 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes personales<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_325 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_325\"><label class=\"quform-label-text\" id=\"quform_6_325_9a10a6_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_325\"><div class=\"quform-input quform-input-radio quform-input-6_325 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_325_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_325\" id=\"quform_6_325_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_325 quform-field-6_325_1\" value=\"No\" \/><label for=\"quform_6_325_9a10a6_1\" class=\"quform-option-label quform-option-label-6_325_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_325\" id=\"quform_6_325_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_325 quform-field-6_325_2\" value=\"Si\" \/><label for=\"quform_6_325_9a10a6_2\" class=\"quform-option-label quform-option-label-6_325_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_326 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_326\"><label class=\"quform-label-text\" for=\"quform_6_326_9a10a6\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_326\"><div class=\"quform-input quform-input-text quform-input-6_326 quform-cf\"><input type=\"text\" id=\"quform_6_326_9a10a6\" name=\"quform_6_326\" class=\"quform-field quform-field-text quform-field-6_326\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_340 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes familiares<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_327 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_327\"><label class=\"quform-label-text\" id=\"quform_6_327_9a10a6_label\">Alguien en su familia ha padecido con anterioridad o padece...<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_327\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-6_327 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_327_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_1\" value=\"Obesidad\" \/><label for=\"quform_6_327_9a10a6_1\" class=\"quform-option-label quform-option-label-6_327_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_6_327_9a10a6_2\" class=\"quform-option-label quform-option-label-6_327_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_6_327_9a10a6_4\" class=\"quform-option-label quform-option-label-6_327_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_6_327_9a10a6_5\" class=\"quform-option-label quform-option-label-6_327_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_11\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_6_327_9a10a6_11\" class=\"quform-option-label quform-option-label-6_327_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_6\" value=\"Asma Bronquial \" \/><label for=\"quform_6_327_9a10a6_6\" class=\"quform-option-label quform-option-label-6_327_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_8\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_6_327_9a10a6_8\" class=\"quform-option-label quform-option-label-6_327_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_10\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_6_327_9a10a6_10\" class=\"quform-option-label quform-option-label-6_327_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_15\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_6_327_9a10a6_15\" class=\"quform-option-label quform-option-label-6_327_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_12\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_6_327_9a10a6_12\" class=\"quform-option-label quform-option-label-6_327_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_327[]\" id=\"quform_6_327_9a10a6_14\" class=\"quform-field quform-field-checkbox quform-field-6_327 quform-field-6_327_14\" value=\"Otros\" \/><label for=\"quform_6_327_9a10a6_14\" class=\"quform-option-label quform-option-label-6_327_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_328 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_328\"><label class=\"quform-label-text\" for=\"quform_6_328_9a10a6\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_328\"><div class=\"quform-input quform-input-textarea quform-input-6_328 quform-cf\"><textarea id=\"quform_6_328_9a10a6\" name=\"quform_6_328\" class=\"quform-field quform-field-textarea quform-field-6_328\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_329 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00e1bitos t\u00f3xicos<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_330 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_330\"><label class=\"quform-label-text\" id=\"quform_6_330_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_330\"><div class=\"quform-input quform-input-radio quform-input-6_330 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_330_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_330\" id=\"quform_6_330_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_330 quform-field-6_330_2\" value=\"Si\" \/><label for=\"quform_6_330_9a10a6_2\" class=\"quform-option-label quform-option-label-6_330_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_330\" id=\"quform_6_330_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_330 quform-field-6_330_1\" value=\"No\" \/><label for=\"quform_6_330_9a10a6_1\" class=\"quform-option-label quform-option-label-6_330_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_330\" id=\"quform_6_330_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_330 quform-field-6_330_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_6_330_9a10a6_4\" class=\"quform-option-label quform-option-label-6_330_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_353 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_353\"><label class=\"quform-label-text\" for=\"quform_6_353_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_353\"><div class=\"quform-input quform-input-text quform-input-6_353 quform-cf\"><input type=\"text\" id=\"quform_6_353_9a10a6\" name=\"quform_6_353\" class=\"quform-field quform-field-text quform-field-6_353\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_331 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_331\"><label class=\"quform-label-text\" id=\"quform_6_331_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_331\"><div class=\"quform-input quform-input-radio quform-input-6_331 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_331_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_331\" id=\"quform_6_331_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_331 quform-field-6_331_2\" value=\"Si\" \/><label for=\"quform_6_331_9a10a6_2\" class=\"quform-option-label quform-option-label-6_331_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_331\" id=\"quform_6_331_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_331 quform-field-6_331_1\" value=\"No\" \/><label for=\"quform_6_331_9a10a6_1\" class=\"quform-option-label quform-option-label-6_331_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_354 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_354\"><label class=\"quform-label-text\" for=\"quform_6_354_9a10a6\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_354\"><div class=\"quform-input quform-input-text quform-input-6_354 quform-cf\"><input type=\"text\" id=\"quform_6_354_9a10a6\" name=\"quform_6_354\" class=\"quform-field quform-field-text quform-field-6_354\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_332 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_332\"><label class=\"quform-label-text\" id=\"quform_6_332_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_332\"><div class=\"quform-input quform-input-radio quform-input-6_332 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_332_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_332\" id=\"quform_6_332_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_332 quform-field-6_332_2\" value=\"Si\" \/><label for=\"quform_6_332_9a10a6_2\" class=\"quform-option-label quform-option-label-6_332_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_332\" id=\"quform_6_332_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_332 quform-field-6_332_1\" value=\"No\" \/><label for=\"quform_6_332_9a10a6_1\" class=\"quform-option-label quform-option-label-6_332_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_333 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_333\"><label class=\"quform-label-text\" id=\"quform_6_333_9a10a6_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_333\"><div class=\"quform-input quform-input-radio quform-input-6_333 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_333_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_333\" id=\"quform_6_333_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_333 quform-field-6_333_2\" value=\"Si\" \/><label for=\"quform_6_333_9a10a6_2\" class=\"quform-option-label quform-option-label-6_333_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_333\" id=\"quform_6_333_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_333 quform-field-6_333_1\" value=\"No\" \/><label for=\"quform_6_333_9a10a6_1\" class=\"quform-option-label quform-option-label-6_333_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_334 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_334\"><label class=\"quform-label-text\" for=\"quform_6_334_9a10a6\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_334\"><div class=\"quform-input quform-input-text quform-input-6_334 quform-cf\"><input type=\"text\" id=\"quform_6_334_9a10a6\" name=\"quform_6_334\" class=\"quform-field quform-field-text quform-field-6_334\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_335 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_335\"><label class=\"quform-label-text\" id=\"quform_6_335_9a10a6_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_335\"><div class=\"quform-input quform-input-radio quform-input-6_335 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_335_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_335\" id=\"quform_6_335_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_335 quform-field-6_335_2\" value=\"Si\" \/><label for=\"quform_6_335_9a10a6_2\" class=\"quform-option-label quform-option-label-6_335_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_335\" id=\"quform_6_335_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_335 quform-field-6_335_1\" value=\"No\" \/><label for=\"quform_6_335_9a10a6_1\" class=\"quform-option-label quform-option-label-6_335_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_336 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_336\"><label class=\"quform-label-text\" for=\"quform_6_336_9a10a6\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_336\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-6_336 quform-cf\"><textarea id=\"quform_6_336_9a10a6\" name=\"quform_6_336\" class=\"quform-field quform-field-textarea quform-field-6_336\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_337 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_337\"><label class=\"quform-label-text\" for=\"quform_6_337_9a10a6\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_337\"><div class=\"quform-input quform-input-textarea quform-input-6_337 quform-cf\"><textarea id=\"quform_6_337_9a10a6\" name=\"quform_6_337\" class=\"quform-field quform-field-textarea quform-field-6_337\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_338 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_338\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_338\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-99 quform-page-6_99 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_100 quform-cf\"><div class=\"quform-spacer\"><h3>Historia cl\u00ednica Trastornos del Sue\u00f1o<\/h3><br \/>\nEn la consulta de Trastorno del Sue\u00f1o es fundamental conocer algunos detalles de su d\u00eda a d\u00eda.<br \/>\n<br \/>\nSu dolencia es nuestra prioridad. En VIDAIR queremos dedicar todo nuestro tiempo a evaluar sus necesidades y buscar una soluci\u00f3n, por ello necesitamos que nos facilite ciertos datos antes de la consulta.<\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_120 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Antecedentes personales<\/strong><\/h4><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_104 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_104\"><label class=\"quform-label-text\" for=\"quform_6_104_9a10a6\">\u00bfCual es su puesto de trabajo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_104\"><div class=\"quform-input quform-input-text quform-input-6_104 quform-cf\"><input type=\"text\" id=\"quform_6_104_9a10a6\" name=\"quform_6_104\" class=\"quform-field quform-field-text quform-field-6_104\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_101 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_101\"><label class=\"quform-label-text\" id=\"quform_6_101_9a10a6_label\">\u00bfQu\u00e9 turnos desarrolla en su puesto de trabajo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_101\"><div class=\"quform-input quform-input-checkbox quform-input-6_101 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_101_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_101[]\" id=\"quform_6_101_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_101 quform-field-6_101_1\" value=\"Ma\u00f1ana\" \/><label for=\"quform_6_101_9a10a6_1\" class=\"quform-option-label quform-option-label-6_101_1\"><span class=\"quform-option-text\">Ma\u00f1ana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_101[]\" id=\"quform_6_101_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_101 quform-field-6_101_2\" value=\"Tarde\" \/><label for=\"quform_6_101_9a10a6_2\" class=\"quform-option-label quform-option-label-6_101_2\"><span class=\"quform-option-text\">Tarde<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_101[]\" id=\"quform_6_101_9a10a6_3\" class=\"quform-field quform-field-checkbox quform-field-6_101 quform-field-6_101_3\" value=\"Ma\u00f1ana y tarde\" \/><label for=\"quform_6_101_9a10a6_3\" class=\"quform-option-label quform-option-label-6_101_3\"><span class=\"quform-option-text\">Ma\u00f1ana y tarde<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_101[]\" id=\"quform_6_101_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_101 quform-field-6_101_4\" value=\"Noche\" \/><label for=\"quform_6_101_9a10a6_4\" class=\"quform-option-label quform-option-label-6_101_4\"><span class=\"quform-option-text\">Noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_101[]\" id=\"quform_6_101_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_101 quform-field-6_101_5\" value=\"Turnos partidos\" \/><label for=\"quform_6_101_9a10a6_5\" class=\"quform-option-label quform-option-label-6_101_5\"><span class=\"quform-option-text\">Turnos partidos<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_119 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_119\"><label class=\"quform-label-text\" id=\"quform_6_119_9a10a6_label\">\u00bfTrabaja como conductor\/a profesional?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_119\"><div class=\"quform-input quform-input-radio quform-input-6_119 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_119_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_119\" id=\"quform_6_119_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_119 quform-field-6_119_1\" value=\"SI\" \/><label for=\"quform_6_119_9a10a6_1\" class=\"quform-option-label quform-option-label-6_119_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_119\" id=\"quform_6_119_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_119 quform-field-6_119_2\" value=\"NO\" \/><label for=\"quform_6_119_9a10a6_2\" class=\"quform-option-label quform-option-label-6_119_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_106 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_106\"><label class=\"quform-label-text\" for=\"quform_6_106_9a10a6\">Tipo de conductor<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_106\"><div class=\"quform-input quform-input-text quform-input-6_106 quform-cf\"><input type=\"text\" id=\"quform_6_106_9a10a6\" name=\"quform_6_106\" class=\"quform-field quform-field-text quform-field-6_106\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_117 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_117\"><label class=\"quform-label-text\" id=\"quform_6_117_9a10a6_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_117\"><div class=\"quform-input quform-input-radio quform-input-6_117 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_117_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_117\" id=\"quform_6_117_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_117 quform-field-6_117_1\" value=\"SI\" \/><label for=\"quform_6_117_9a10a6_1\" class=\"quform-option-label quform-option-label-6_117_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_117\" id=\"quform_6_117_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_117 quform-field-6_117_2\" value=\"NO\" \/><label for=\"quform_6_117_9a10a6_2\" class=\"quform-option-label quform-option-label-6_117_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_117\" id=\"quform_6_117_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_117 quform-field-6_117_4\" value=\"EX FUMADOR\/A\" \/><label for=\"quform_6_117_9a10a6_4\" class=\"quform-option-label quform-option-label-6_117_4\"><span class=\"quform-option-text\">EX FUMADOR\/A<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_108 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_108\"><label class=\"quform-label-text\" for=\"quform_6_108_9a10a6\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_108\"><div class=\"quform-input quform-input-text quform-input-6_108 quform-cf\"><input type=\"text\" id=\"quform_6_108_9a10a6\" name=\"quform_6_108\" class=\"quform-field quform-field-text quform-field-6_108\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_109 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_109\"><label class=\"quform-label-text\" for=\"quform_6_109_9a10a6\">\u00bfDesde qu\u00e9 edad y hasta qu\u00e9 edad fue fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_109\"><div class=\"quform-input quform-input-text quform-input-6_109 quform-cf\"><input type=\"text\" id=\"quform_6_109_9a10a6\" name=\"quform_6_109\" class=\"quform-field quform-field-text quform-field-6_109\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_110 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_110\"><label class=\"quform-label-text\" for=\"quform_6_110_9a10a6\">\u00bfCu\u00e1nto fumaba aproximadamente?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_110\"><div class=\"quform-input quform-input-text quform-input-6_110 quform-cf\"><input type=\"text\" id=\"quform_6_110_9a10a6\" name=\"quform_6_110\" class=\"quform-field quform-field-text quform-field-6_110\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_118 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_118\"><label class=\"quform-label-text\" id=\"quform_6_118_9a10a6_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_118\"><div class=\"quform-input quform-input-radio quform-input-6_118 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_118_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_118\" id=\"quform_6_118_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_118 quform-field-6_118_1\" value=\"SI\" \/><label for=\"quform_6_118_9a10a6_1\" class=\"quform-option-label quform-option-label-6_118_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_118\" id=\"quform_6_118_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_118 quform-field-6_118_2\" value=\"NO\" \/><label for=\"quform_6_118_9a10a6_2\" class=\"quform-option-label quform-option-label-6_118_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_112 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_112\"><label class=\"quform-label-text\" for=\"quform_6_112_9a10a6\">\u00bfCu\u00e1nto alcohol consume al d\u00eda?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_112\"><div class=\"quform-input quform-input-text quform-input-6_112 quform-cf\"><input type=\"text\" id=\"quform_6_112_9a10a6\" name=\"quform_6_112\" class=\"quform-field quform-field-text quform-field-6_112\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_116 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_116\"><label class=\"quform-label-text\" id=\"quform_6_116_9a10a6_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_116\"><div class=\"quform-input quform-input-radio quform-input-6_116 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_116_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_116\" id=\"quform_6_116_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_116 quform-field-6_116_1\" value=\"SI\" \/><label for=\"quform_6_116_9a10a6_1\" class=\"quform-option-label quform-option-label-6_116_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_116\" id=\"quform_6_116_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_116 quform-field-6_116_2\" value=\"NO\" \/><label for=\"quform_6_116_9a10a6_2\" class=\"quform-option-label quform-option-label-6_116_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_114 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_114\"><label class=\"quform-label-text\" for=\"quform_6_114_9a10a6\">Nombre del medicamento, miligramos y dosis<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_114\"><div class=\"quform-input quform-input-text quform-input-6_114 quform-cf\"><input type=\"text\" id=\"quform_6_114_9a10a6\" name=\"quform_6_114\" class=\"quform-field quform-field-text quform-field-6_114\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_121 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Signos y s\u00edntomas de Trastornos Respiratorios del Sue\u00f1o<\/strong><\/h4><br \/>\nPor favor, lea detenidamente cada una de las siguientes preguntas, y seleccione con la respuesta que m\u00e1s se asemeje a lo que le est\u00e1 ocurriendo actualmente.<\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_123 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_124\"><div class=\"quform-element quform-element-text quform-element-6_132 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_132\"><label class=\"quform-label-text\" for=\"quform_6_132_9a10a6\">\u00bfA qu\u00e9 hora se acuesta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_132\"><div class=\"quform-input quform-input-text quform-input-6_132 quform-cf\"><input type=\"text\" id=\"quform_6_132_9a10a6\" name=\"quform_6_132\" class=\"quform-field quform-field-text quform-field-6_132\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_125\"><div class=\"quform-element quform-element-text quform-element-6_127 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_127\"><label class=\"quform-label-text\" for=\"quform_6_127_9a10a6\">\u00bfA qu\u00e9 hora se despierta-levanta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_127\"><div class=\"quform-input quform-input-text quform-input-6_127 quform-cf\"><input type=\"text\" id=\"quform_6_127_9a10a6\" name=\"quform_6_127\" class=\"quform-field quform-field-text quform-field-6_127\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_130 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_130\"><label class=\"quform-label-text\" id=\"quform_6_130_9a10a6_label\">\u00bfCu\u00e1nto tiempo dura para dormirse?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_130\"><div class=\"quform-input quform-input-radio quform-input-6_130 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_130_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_130\" id=\"quform_6_130_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_130 quform-field-6_130_1\" value=\"Menos de 30 minutos\" \/><label for=\"quform_6_130_9a10a6_1\" class=\"quform-option-label quform-option-label-6_130_1\"><span class=\"quform-option-text\">Menos de 30 minutos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_130\" id=\"quform_6_130_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_130 quform-field-6_130_2\" value=\"30 minutos - 1 hora\" \/><label for=\"quform_6_130_9a10a6_2\" class=\"quform-option-label quform-option-label-6_130_2\"><span class=\"quform-option-text\">30 minutos - 1 hora<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_130\" id=\"quform_6_130_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_130 quform-field-6_130_3\" value=\"1 - 2 horas\" \/><label for=\"quform_6_130_9a10a6_3\" class=\"quform-option-label quform-option-label-6_130_3\"><span class=\"quform-option-text\">1 - 2 horas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_130\" id=\"quform_6_130_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_130 quform-field-6_130_4\" value=\"M\u00e1s de 2 horas\" \/><label for=\"quform_6_130_9a10a6_4\" class=\"quform-option-label quform-option-label-6_130_4\"><span class=\"quform-option-text\">M\u00e1s de 2 horas<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_131 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_131\"><label class=\"quform-label-text\" id=\"quform_6_131_9a10a6_label\">\u00bfDuerme la siesta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_131\"><div class=\"quform-input quform-input-radio quform-input-6_131 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_131_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_131\" id=\"quform_6_131_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_131 quform-field-6_131_1\" value=\"SI\" \/><label for=\"quform_6_131_9a10a6_1\" class=\"quform-option-label quform-option-label-6_131_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_131\" id=\"quform_6_131_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_131 quform-field-6_131_2\" value=\"NO\" \/><label for=\"quform_6_131_9a10a6_2\" class=\"quform-option-label quform-option-label-6_131_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_126 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_126\"><label class=\"quform-label-text\" for=\"quform_6_126_9a10a6\">\u00bfCu\u00e1nto suelen durar sus siestas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_126\"><div class=\"quform-input quform-input-text quform-input-6_126 quform-cf\"><input type=\"text\" id=\"quform_6_126_9a10a6\" name=\"quform_6_126\" class=\"quform-field quform-field-text quform-field-6_126\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_133 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_133\"><label class=\"quform-label-text\" id=\"quform_6_133_9a10a6_label\">\u00bfPresenta ronquidos?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_133\"><div class=\"quform-input quform-input-radio quform-input-6_133 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_133_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_133\" id=\"quform_6_133_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_133 quform-field-6_133_1\" value=\"SI\" \/><label for=\"quform_6_133_9a10a6_1\" class=\"quform-option-label quform-option-label-6_133_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_133\" id=\"quform_6_133_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_133 quform-field-6_133_2\" value=\"NO\" \/><label for=\"quform_6_133_9a10a6_2\" class=\"quform-option-label quform-option-label-6_133_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_134 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_134\"><label class=\"quform-label-text\" id=\"quform_6_134_9a10a6_label\">\u00bfDesde cu\u00e1ndo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_134\"><div class=\"quform-input quform-input-radio quform-input-6_134 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_134_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_134\" id=\"quform_6_134_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_134 quform-field-6_134_1\" value=\"Menos de 1 a\u00f1o\" \/><label for=\"quform_6_134_9a10a6_1\" class=\"quform-option-label quform-option-label-6_134_1\"><span class=\"quform-option-text\">Menos de 1 a\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_134\" id=\"quform_6_134_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_134 quform-field-6_134_2\" value=\"De 1 a 3 a\u00f1os\" \/><label for=\"quform_6_134_9a10a6_2\" class=\"quform-option-label quform-option-label-6_134_2\"><span class=\"quform-option-text\">De 1 a 3 a\u00f1os<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_134\" id=\"quform_6_134_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_134 quform-field-6_134_3\" value=\"De 3 a 5 a\u00f1os\" \/><label for=\"quform_6_134_9a10a6_3\" class=\"quform-option-label quform-option-label-6_134_3\"><span class=\"quform-option-text\">De 3 a 5 a\u00f1os<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_134\" id=\"quform_6_134_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_134 quform-field-6_134_4\" value=\"M\u00e1s de 5 a\u00f1os\" \/><label for=\"quform_6_134_9a10a6_4\" class=\"quform-option-label quform-option-label-6_134_4\"><span class=\"quform-option-text\">M\u00e1s de 5 a\u00f1os<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-6_145 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_137 quform-cf\"><div class=\"quform-spacer\"><h4>Con relaci\u00f3n a su ronquido<\/h4><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_146 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_147\"><div class=\"quform-element quform-element-radio quform-element-6_138 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_138\"><label class=\"quform-label-text\" id=\"quform_6_138_9a10a6_label\">\u00bfSu ronquido se escucha fuera de la habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_138\"><div class=\"quform-input quform-input-radio quform-input-6_138 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_138_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_138\" id=\"quform_6_138_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_138 quform-field-6_138_1\" value=\"SI\" \/><label for=\"quform_6_138_9a10a6_1\" class=\"quform-option-label quform-option-label-6_138_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_138\" id=\"quform_6_138_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_138 quform-field-6_138_2\" value=\"NO\" \/><label for=\"quform_6_138_9a10a6_2\" class=\"quform-option-label quform-option-label-6_138_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_138\" id=\"quform_6_138_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_138 quform-field-6_138_5\" value=\"A VECES\" \/><label for=\"quform_6_138_9a10a6_5\" class=\"quform-option-label quform-option-label-6_138_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_138\" id=\"quform_6_138_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_138 quform-field-6_138_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_138_9a10a6_6\" class=\"quform-option-label quform-option-label-6_138_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_148\"><div class=\"quform-element quform-element-radio quform-element-6_140 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_140\"><label class=\"quform-label-text\" id=\"quform_6_140_9a10a6_label\">\u00bfSu ronquido despierta a su compa\u00f1ero de cama - habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_140\"><div class=\"quform-input quform-input-radio quform-input-6_140 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_140_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_140\" id=\"quform_6_140_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_140 quform-field-6_140_1\" value=\"SI\" \/><label for=\"quform_6_140_9a10a6_1\" class=\"quform-option-label quform-option-label-6_140_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_140\" id=\"quform_6_140_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_140 quform-field-6_140_2\" value=\"NO\" \/><label for=\"quform_6_140_9a10a6_2\" class=\"quform-option-label quform-option-label-6_140_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_140\" id=\"quform_6_140_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_140 quform-field-6_140_5\" value=\"A VECES\" \/><label for=\"quform_6_140_9a10a6_5\" class=\"quform-option-label quform-option-label-6_140_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_140\" id=\"quform_6_140_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_140 quform-field-6_140_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_140_9a10a6_6\" class=\"quform-option-label quform-option-label-6_140_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_149 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_150\"><div class=\"quform-element quform-element-radio quform-element-6_141 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_141\"><label class=\"quform-label-text\" id=\"quform_6_141_9a10a6_label\">\u00bfSu ronquido provoca insomnio a su compa\u00f1ero\/a de cama - habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_141\"><div class=\"quform-input quform-input-radio quform-input-6_141 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_141_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_141\" id=\"quform_6_141_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_141 quform-field-6_141_1\" value=\"SI\" \/><label for=\"quform_6_141_9a10a6_1\" class=\"quform-option-label quform-option-label-6_141_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_141\" id=\"quform_6_141_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_141 quform-field-6_141_2\" value=\"NO\" \/><label for=\"quform_6_141_9a10a6_2\" class=\"quform-option-label quform-option-label-6_141_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_141\" id=\"quform_6_141_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_141 quform-field-6_141_5\" value=\"A VECES\" \/><label for=\"quform_6_141_9a10a6_5\" class=\"quform-option-label quform-option-label-6_141_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_141\" id=\"quform_6_141_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_141 quform-field-6_141_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_141_9a10a6_6\" class=\"quform-option-label quform-option-label-6_141_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_152\"><div class=\"quform-element quform-element-radio quform-element-6_142 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_142\"><label class=\"quform-label-text\" id=\"quform_6_142_9a10a6_label\">\u00bfSu ronquido obliga a su compa\u00f1ero de cama \/ habitaci\u00f3n a dormir en otra habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_142\"><div class=\"quform-input quform-input-radio quform-input-6_142 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_142_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_142\" id=\"quform_6_142_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_142 quform-field-6_142_1\" value=\"SI\" \/><label for=\"quform_6_142_9a10a6_1\" class=\"quform-option-label quform-option-label-6_142_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_142\" id=\"quform_6_142_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_142 quform-field-6_142_2\" value=\"NO\" \/><label for=\"quform_6_142_9a10a6_2\" class=\"quform-option-label quform-option-label-6_142_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_142\" id=\"quform_6_142_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_142 quform-field-6_142_5\" value=\"A VECES\" \/><label for=\"quform_6_142_9a10a6_5\" class=\"quform-option-label quform-option-label-6_142_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_142\" id=\"quform_6_142_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_142 quform-field-6_142_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_142_9a10a6_6\" class=\"quform-option-label quform-option-label-6_142_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-6_155 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-6_156\"><div class=\"quform-element quform-element-radio quform-element-6_143 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_143\"><label class=\"quform-label-text\" id=\"quform_6_143_9a10a6_label\">\u00bfLe han dicho que hace paradas respiratorias mientras duerme (apneas)?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_143\"><div class=\"quform-input quform-input-radio quform-input-6_143 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_143_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_143\" id=\"quform_6_143_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_143 quform-field-6_143_1\" value=\"SI\" \/><label for=\"quform_6_143_9a10a6_1\" class=\"quform-option-label quform-option-label-6_143_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_143\" id=\"quform_6_143_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_143 quform-field-6_143_2\" value=\"NO\" \/><label for=\"quform_6_143_9a10a6_2\" class=\"quform-option-label quform-option-label-6_143_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_143\" id=\"quform_6_143_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_143 quform-field-6_143_5\" value=\"A VECES\" \/><label for=\"quform_6_143_9a10a6_5\" class=\"quform-option-label quform-option-label-6_143_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_143\" id=\"quform_6_143_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_143 quform-field-6_143_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_143_9a10a6_6\" class=\"quform-option-label quform-option-label-6_143_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-6_158\"><div class=\"quform-element quform-element-radio quform-element-6_144 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_144\"><label class=\"quform-label-text\" id=\"quform_6_144_9a10a6_label\">\u00bfSe despierta con falta de aire o sensaci\u00f3n de ahogo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_144\"><div class=\"quform-input quform-input-radio quform-input-6_144 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_144_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_144\" id=\"quform_6_144_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_144 quform-field-6_144_1\" value=\"SI\" \/><label for=\"quform_6_144_9a10a6_1\" class=\"quform-option-label quform-option-label-6_144_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_144\" id=\"quform_6_144_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_144 quform-field-6_144_2\" value=\"NO\" \/><label for=\"quform_6_144_9a10a6_2\" class=\"quform-option-label quform-option-label-6_144_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_144\" id=\"quform_6_144_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_144 quform-field-6_144_5\" value=\"A VECES\" \/><label for=\"quform_6_144_9a10a6_5\" class=\"quform-option-label quform-option-label-6_144_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_144\" id=\"quform_6_144_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_144 quform-field-6_144_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_6_144_9a10a6_6\" class=\"quform-option-label quform-option-label-6_144_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_160 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_160\"><label class=\"quform-label-text\" id=\"quform_6_160_9a10a6_label\">\u00bfSe levanta a orinar durante la noche?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_160\"><div class=\"quform-input quform-input-radio quform-input-6_160 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_160_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_160\" id=\"quform_6_160_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_160 quform-field-6_160_1\" value=\"SI\" \/><label for=\"quform_6_160_9a10a6_1\" class=\"quform-option-label quform-option-label-6_160_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_160\" id=\"quform_6_160_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_160 quform-field-6_160_2\" value=\"NO\" \/><label for=\"quform_6_160_9a10a6_2\" class=\"quform-option-label quform-option-label-6_160_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_161 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_161\"><label class=\"quform-label-text\" id=\"quform_6_161_9a10a6_label\">\u00bfCu\u00e1ntas veces?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_161\"><div class=\"quform-input quform-input-radio quform-input-6_161 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_161_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_161\" id=\"quform_6_161_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_161 quform-field-6_161_1\" value=\"1 \/ 2 por noche\" \/><label for=\"quform_6_161_9a10a6_1\" class=\"quform-option-label quform-option-label-6_161_1\"><span class=\"quform-option-text\">1 \/ 2 por noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_161\" id=\"quform_6_161_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_161 quform-field-6_161_2\" value=\"M\u00e1s de 2 veces por noche\" \/><label for=\"quform_6_161_9a10a6_2\" class=\"quform-option-label quform-option-label-6_161_2\"><span class=\"quform-option-text\">M\u00e1s de 2 veces por noche<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_162 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_162\"><label class=\"quform-label-text\" id=\"quform_6_162_9a10a6_label\">\u00bfSe despierta durante la noche, despertares de larga duraci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_162\"><div class=\"quform-input quform-input-radio quform-input-6_162 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_162_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_162\" id=\"quform_6_162_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_162 quform-field-6_162_1\" value=\"SI\" \/><label for=\"quform_6_162_9a10a6_1\" class=\"quform-option-label quform-option-label-6_162_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_162\" id=\"quform_6_162_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_162 quform-field-6_162_2\" value=\"NO\" \/><label for=\"quform_6_162_9a10a6_2\" class=\"quform-option-label quform-option-label-6_162_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-6_164 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_164\"><label class=\"quform-label-text\" id=\"quform_6_164_9a10a6_label\">\u00bfCu\u00e1l suele ser el motivo de su desvelo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-6_164\"><div class=\"quform-input quform-input-checkbox quform-input-6_164 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_6_164_9a10a6_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_1\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_1\" value=\"Orinar\" \/><label for=\"quform_6_164_9a10a6_1\" class=\"quform-option-label quform-option-label-6_164_1\"><span class=\"quform-option-text\">Orinar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_2\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_2\" value=\"Dolor\" \/><label for=\"quform_6_164_9a10a6_2\" class=\"quform-option-label quform-option-label-6_164_2\"><span class=\"quform-option-text\">Dolor<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_3\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_3\" value=\"No sabe\" \/><label for=\"quform_6_164_9a10a6_3\" class=\"quform-option-label quform-option-label-6_164_3\"><span class=\"quform-option-text\">No sabe<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_4\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_4\" value=\"Pesadillas\" \/><label for=\"quform_6_164_9a10a6_4\" class=\"quform-option-label quform-option-label-6_164_4\"><span class=\"quform-option-text\">Pesadillas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_5\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_5\" value=\"Ruidos\" \/><label for=\"quform_6_164_9a10a6_5\" class=\"quform-option-label quform-option-label-6_164_5\"><span class=\"quform-option-text\">Ruidos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_6_164[]\" id=\"quform_6_164_9a10a6_6\" class=\"quform-field quform-field-checkbox quform-field-6_164 quform-field-6_164_6\" value=\"Otros\" \/><label for=\"quform_6_164_9a10a6_6\" class=\"quform-option-label quform-option-label-6_164_6\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-6_165 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_165\"><label class=\"quform-label-text\" for=\"quform_6_165_9a10a6\">Cu\u00e9ntenos el motivo de su desvelo<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-6_165\"><div class=\"quform-input quform-input-text quform-input-6_165 quform-cf\"><input type=\"text\" id=\"quform_6_165_9a10a6\" name=\"quform_6_165\" class=\"quform-field quform-field-text quform-field-6_165\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_166 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_166\"><label class=\"quform-label-text\" id=\"quform_6_166_9a10a6_label\">\u00bfDespierta varias veces durante la noche sin motivo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_166\"><div class=\"quform-input quform-input-radio quform-input-6_166 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_166_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_166\" id=\"quform_6_166_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_166 quform-field-6_166_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_6_166_9a10a6_1\" class=\"quform-option-label quform-option-label-6_166_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_166\" id=\"quform_6_166_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_166 quform-field-6_166_2\" value=\" 2 veces o m\u00e1s por noche\" \/><label for=\"quform_6_166_9a10a6_2\" class=\"quform-option-label quform-option-label-6_166_2\"><span class=\"quform-option-text\"> 2 veces o m\u00e1s por noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_166\" id=\"quform_6_166_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_166 quform-field-6_166_5\" value=\"Diario\" \/><label for=\"quform_6_166_9a10a6_5\" class=\"quform-option-label quform-option-label-6_166_5\"><span class=\"quform-option-text\">Diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_167 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_167\"><label class=\"quform-label-text\" id=\"quform_6_167_9a10a6_label\">\u00bfCu\u00e1ndo amanece, tiene la sensaci\u00f3n de que no ha dormido \/ descansado correctamente? (Sue\u00f1o no reparador)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_167\"><div class=\"quform-input quform-input-radio quform-input-6_167 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_167_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_167\" id=\"quform_6_167_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_167 quform-field-6_167_1\" value=\"Nunca\" \/><label for=\"quform_6_167_9a10a6_1\" class=\"quform-option-label quform-option-label-6_167_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_167\" id=\"quform_6_167_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_167 quform-field-6_167_2\" value=\"Casi nunca\" \/><label for=\"quform_6_167_9a10a6_2\" class=\"quform-option-label quform-option-label-6_167_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_167\" id=\"quform_6_167_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_167 quform-field-6_167_5\" value=\"A veces\" \/><label for=\"quform_6_167_9a10a6_5\" class=\"quform-option-label quform-option-label-6_167_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_167\" id=\"quform_6_167_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_167 quform-field-6_167_6\" value=\"Siempre\" \/><label for=\"quform_6_167_9a10a6_6\" class=\"quform-option-label quform-option-label-6_167_6\"><span class=\"quform-option-text\">Siempre<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_168 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_168\"><label class=\"quform-label-text\" id=\"quform_6_168_9a10a6_label\">\u00bfLe cuesta despertarse \/ levantarse por la ma\u00f1ana?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_168\"><div class=\"quform-input quform-input-radio quform-input-6_168 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_168_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_168\" id=\"quform_6_168_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_168 quform-field-6_168_1\" value=\"Nunca\" \/><label for=\"quform_6_168_9a10a6_1\" class=\"quform-option-label quform-option-label-6_168_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_168\" id=\"quform_6_168_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_168 quform-field-6_168_2\" value=\"Casi nunca\" \/><label for=\"quform_6_168_9a10a6_2\" class=\"quform-option-label quform-option-label-6_168_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_168\" id=\"quform_6_168_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_168 quform-field-6_168_5\" value=\"A veces\" \/><label for=\"quform_6_168_9a10a6_5\" class=\"quform-option-label quform-option-label-6_168_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_168\" id=\"quform_6_168_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_168 quform-field-6_168_6\" value=\"Siempre\" \/><label for=\"quform_6_168_9a10a6_6\" class=\"quform-option-label quform-option-label-6_168_6\"><span class=\"quform-option-text\">Siempre<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_169 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_169\"><label class=\"quform-label-text\" id=\"quform_6_169_9a10a6_label\">\u00bfPresenta cansancio o falta de energ\u00eda durante el d\u00eda?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_169\"><div class=\"quform-input quform-input-radio quform-input-6_169 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_169_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_169\" id=\"quform_6_169_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_169 quform-field-6_169_1\" value=\"Nunca\" \/><label for=\"quform_6_169_9a10a6_1\" class=\"quform-option-label quform-option-label-6_169_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_169\" id=\"quform_6_169_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_169 quform-field-6_169_2\" value=\"Casi nunca\" \/><label for=\"quform_6_169_9a10a6_2\" class=\"quform-option-label quform-option-label-6_169_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_169\" id=\"quform_6_169_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_169 quform-field-6_169_5\" value=\"A veces\" \/><label for=\"quform_6_169_9a10a6_5\" class=\"quform-option-label quform-option-label-6_169_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_169\" id=\"quform_6_169_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_169 quform-field-6_169_6\" value=\"Muchas veces\" \/><label for=\"quform_6_169_9a10a6_6\" class=\"quform-option-label quform-option-label-6_169_6\"><span class=\"quform-option-text\">Muchas veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_169\" id=\"quform_6_169_9a10a6_7\" class=\"quform-field quform-field-radio quform-field-6_169 quform-field-6_169_7\" value=\"A diario\" \/><label for=\"quform_6_169_9a10a6_7\" class=\"quform-option-label quform-option-label-6_169_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_170 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_170\"><label class=\"quform-label-text\" id=\"quform_6_170_9a10a6_label\">\u00bfPresenta dificultad para realizar sus actividades de la vida diaria por cansancio o falta de concentraci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_170\"><div class=\"quform-input quform-input-radio quform-input-6_170 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_170_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_170\" id=\"quform_6_170_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_170 quform-field-6_170_1\" value=\"Nunca\" \/><label for=\"quform_6_170_9a10a6_1\" class=\"quform-option-label quform-option-label-6_170_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_170\" id=\"quform_6_170_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_170 quform-field-6_170_2\" value=\"Casi nunca\" \/><label for=\"quform_6_170_9a10a6_2\" class=\"quform-option-label quform-option-label-6_170_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_170\" id=\"quform_6_170_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_170 quform-field-6_170_5\" value=\"A veces\" \/><label for=\"quform_6_170_9a10a6_5\" class=\"quform-option-label quform-option-label-6_170_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_170\" id=\"quform_6_170_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_170 quform-field-6_170_6\" value=\"Muchas veces a la semana\" \/><label for=\"quform_6_170_9a10a6_6\" class=\"quform-option-label quform-option-label-6_170_6\"><span class=\"quform-option-text\">Muchas veces a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_170\" id=\"quform_6_170_9a10a6_7\" class=\"quform-field quform-field-radio quform-field-6_170 quform-field-6_170_7\" value=\"A diario\" \/><label for=\"quform_6_170_9a10a6_7\" class=\"quform-option-label quform-option-label-6_170_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_171 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_171\"><label class=\"quform-label-text\" id=\"quform_6_171_9a10a6_label\">\u00bfCu\u00e1ndo sue\u00f1a, recuerda el sue\u00f1o tras despertar?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_171\"><div class=\"quform-input quform-input-radio quform-input-6_171 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_171_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_171\" id=\"quform_6_171_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_171 quform-field-6_171_1\" value=\"Nunca\" \/><label for=\"quform_6_171_9a10a6_1\" class=\"quform-option-label quform-option-label-6_171_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_171\" id=\"quform_6_171_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_171 quform-field-6_171_2\" value=\"Casi nunca\" \/><label for=\"quform_6_171_9a10a6_2\" class=\"quform-option-label quform-option-label-6_171_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_171\" id=\"quform_6_171_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_171 quform-field-6_171_5\" value=\"A veces\" \/><label for=\"quform_6_171_9a10a6_5\" class=\"quform-option-label quform-option-label-6_171_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_171\" id=\"quform_6_171_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_171 quform-field-6_171_6\" value=\"Muchas veces\" \/><label for=\"quform_6_171_9a10a6_6\" class=\"quform-option-label quform-option-label-6_171_6\"><span class=\"quform-option-text\">Muchas veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_171\" id=\"quform_6_171_9a10a6_7\" class=\"quform-field quform-field-radio quform-field-6_171 quform-field-6_171_7\" value=\"A diario\" \/><label for=\"quform_6_171_9a10a6_7\" class=\"quform-option-label quform-option-label-6_171_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_172 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_172\"><label class=\"quform-label-text\" id=\"quform_6_172_9a10a6_label\">\u00bfPresenta dificultad para respirar, fatiga o falta de aire?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_172\"><div class=\"quform-input quform-input-radio quform-input-6_172 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_172_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_172\" id=\"quform_6_172_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_172 quform-field-6_172_1\" value=\"Nunca\" \/><label for=\"quform_6_172_9a10a6_1\" class=\"quform-option-label quform-option-label-6_172_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_172\" id=\"quform_6_172_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_172 quform-field-6_172_2\" value=\"S\u00f3lo al caminar de prisa o subir una cuesta\" \/><label for=\"quform_6_172_9a10a6_2\" class=\"quform-option-label quform-option-label-6_172_2\"><span class=\"quform-option-text\">S\u00f3lo al caminar de prisa o subir una cuesta<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_172\" id=\"quform_6_172_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_172 quform-field-6_172_5\" value=\"Debo parar al caminar en llano\" \/><label for=\"quform_6_172_9a10a6_5\" class=\"quform-option-label quform-option-label-6_172_5\"><span class=\"quform-option-text\">Debo parar al caminar en llano<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_172\" id=\"quform_6_172_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_172 quform-field-6_172_6\" value=\"Tengo limitaci\u00f3n al vestirme en casa\" \/><label for=\"quform_6_172_9a10a6_6\" class=\"quform-option-label quform-option-label-6_172_6\"><span class=\"quform-option-text\">Tengo limitaci\u00f3n al vestirme en casa<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_173 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_173\"><label class=\"quform-label-text\" id=\"quform_6_173_9a10a6_label\">\u00bfAl despertar, tiene dolor de cabeza?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_173\"><div class=\"quform-input quform-input-radio quform-input-6_173 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_173_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_173\" id=\"quform_6_173_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_173 quform-field-6_173_1\" value=\"Nunca\" \/><label for=\"quform_6_173_9a10a6_1\" class=\"quform-option-label quform-option-label-6_173_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_173\" id=\"quform_6_173_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_173 quform-field-6_173_2\" value=\"Casi nunca\" \/><label for=\"quform_6_173_9a10a6_2\" class=\"quform-option-label quform-option-label-6_173_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_173\" id=\"quform_6_173_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_173 quform-field-6_173_5\" value=\"A veces\" \/><label for=\"quform_6_173_9a10a6_5\" class=\"quform-option-label quform-option-label-6_173_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_173\" id=\"quform_6_173_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_173 quform-field-6_173_6\" value=\"Muchas veces a la semana\" \/><label for=\"quform_6_173_9a10a6_6\" class=\"quform-option-label quform-option-label-6_173_6\"><span class=\"quform-option-text\">Muchas veces a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_173\" id=\"quform_6_173_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_173 quform-field-6_173_8\" value=\"A diario\" \/><label for=\"quform_6_173_9a10a6_8\" class=\"quform-option-label quform-option-label-6_173_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_174 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_174\"><label class=\"quform-label-text\" id=\"quform_6_174_9a10a6_label\">\u00bfNota sue\u00f1o durante el d\u00eda en horas no habituales (Somnolencia Excesiva Diurna)?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_174\"><div class=\"quform-input quform-input-radio quform-input-6_174 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_174_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_174\" id=\"quform_6_174_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_174 quform-field-6_174_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_6_174_9a10a6_1\" class=\"quform-option-label quform-option-label-6_174_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_174\" id=\"quform_6_174_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_174 quform-field-6_174_5\" value=\"A veces\" \/><label for=\"quform_6_174_9a10a6_5\" class=\"quform-option-label quform-option-label-6_174_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_174\" id=\"quform_6_174_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_174 quform-field-6_174_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_6_174_9a10a6_6\" class=\"quform-option-label quform-option-label-6_174_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_174\" id=\"quform_6_174_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_174 quform-field-6_174_8\" value=\"A diario\" \/><label for=\"quform_6_174_9a10a6_8\" class=\"quform-option-label quform-option-label-6_174_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_175 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_175\"><label class=\"quform-label-text\" id=\"quform_6_175_9a10a6_label\">\u00bfDificulta la somnolencia realizar sus actividades de la vida diaria?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_175\"><div class=\"quform-input quform-input-radio quform-input-6_175 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_175_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_175\" id=\"quform_6_175_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_175 quform-field-6_175_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_6_175_9a10a6_1\" class=\"quform-option-label quform-option-label-6_175_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_175\" id=\"quform_6_175_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_175 quform-field-6_175_5\" value=\"A veces\" \/><label for=\"quform_6_175_9a10a6_5\" class=\"quform-option-label quform-option-label-6_175_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_175\" id=\"quform_6_175_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_175 quform-field-6_175_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_6_175_9a10a6_6\" class=\"quform-option-label quform-option-label-6_175_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_175\" id=\"quform_6_175_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_175 quform-field-6_175_8\" value=\"A diario\" \/><label for=\"quform_6_175_9a10a6_8\" class=\"quform-option-label quform-option-label-6_175_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_176 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_176\"><label class=\"quform-label-text\" id=\"quform_6_176_9a10a6_label\">\u00bfCu\u00e1ndo se acuesta, presenta hormigueo en las piernas o necesidad de moverlas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_176\"><div class=\"quform-input quform-input-radio quform-input-6_176 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_176_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_176\" id=\"quform_6_176_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_176 quform-field-6_176_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_6_176_9a10a6_1\" class=\"quform-option-label quform-option-label-6_176_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_176\" id=\"quform_6_176_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_176 quform-field-6_176_5\" value=\"A veces\" \/><label for=\"quform_6_176_9a10a6_5\" class=\"quform-option-label quform-option-label-6_176_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_176\" id=\"quform_6_176_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_176 quform-field-6_176_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_6_176_9a10a6_6\" class=\"quform-option-label quform-option-label-6_176_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_176\" id=\"quform_6_176_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_176 quform-field-6_176_8\" value=\"A diario\" \/><label for=\"quform_6_176_9a10a6_8\" class=\"quform-option-label quform-option-label-6_176_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_177 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_177\"><label class=\"quform-label-text\" id=\"quform_6_177_9a10a6_label\">Mientras duerme, \u00bftiene movimientos continuos o bruscos con las piernas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_177\"><div class=\"quform-input quform-input-radio quform-input-6_177 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_177_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_177\" id=\"quform_6_177_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_177 quform-field-6_177_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_6_177_9a10a6_1\" class=\"quform-option-label quform-option-label-6_177_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_177\" id=\"quform_6_177_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_177 quform-field-6_177_5\" value=\"A veces\" \/><label for=\"quform_6_177_9a10a6_5\" class=\"quform-option-label quform-option-label-6_177_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_177\" id=\"quform_6_177_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_177 quform-field-6_177_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_6_177_9a10a6_6\" class=\"quform-option-label quform-option-label-6_177_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_177\" id=\"quform_6_177_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_177 quform-field-6_177_8\" value=\"A diario\" \/><label for=\"quform_6_177_9a10a6_8\" class=\"quform-option-label quform-option-label-6_177_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-6_102 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_102\"><label class=\"quform-label-text\" for=\"quform_6_102_9a10a6\">Otros signos o s\u00edntomas que desee registrar<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-6_102\"><div class=\"quform-input quform-input-textarea quform-input-6_102 quform-cf\"><textarea id=\"quform_6_102_9a10a6\" name=\"quform_6_102\" class=\"quform-field quform-field-textarea quform-field-6_102\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-6_178 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Valoraci\u00f3n de la Somnolencia<\/strong><\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_179 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_179\"><label class=\"quform-label-text\" id=\"quform_6_179_9a10a6_label\">Excesiva Somnolencia Diurna (ESD). \u00bfPresenta excesiva Somnolencia Diurna? <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_179\"><div class=\"quform-input quform-input-radio quform-input-6_179 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_179_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_179\" id=\"quform_6_179_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_179 quform-field-6_179_1\" value=\"No\" \/><label for=\"quform_6_179_9a10a6_1\" class=\"quform-option-label quform-option-label-6_179_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_179\" id=\"quform_6_179_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_179 quform-field-6_179_5\" value=\"Leve (Episodios de somnolencia mientras se encuentra en situaciones pasivas: viendo la televisi\u00f3n, leer en cama al anochecer, mientras viaja como pasajero etc.).\" \/><label for=\"quform_6_179_9a10a6_5\" class=\"quform-option-label quform-option-label-6_179_5\"><span class=\"quform-option-text\">Leve (Episodios de somnolencia mientras se encuentra en situaciones pasivas: viendo la televisi\u00f3n, leer en cama al anochecer, mientras viaja como pasajero etc.).<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_179\" id=\"quform_6_179_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_179 quform-field-6_179_6\" value=\"Moderada (Episodios de somnolencia que se dan en situaciones  donde se requiere cierto grado de atenci\u00f3n, situaciones activas: en el culto o misa, un concierto,  reuni\u00f3n, cine, etc.).\" \/><label for=\"quform_6_179_9a10a6_6\" class=\"quform-option-label quform-option-label-6_179_6\"><span class=\"quform-option-text\">Moderada (Episodios de somnolencia que se dan en situaciones  donde se requiere cierto grado de atenci\u00f3n, situaciones activas: en el culto o misa, un concierto,  reuni\u00f3n, cine, etc.).<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_179\" id=\"quform_6_179_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_179 quform-field-6_179_8\" value=\"Grave (Episodios de somnolencia diario que se dan en situaciones muy activas: Comer,  estar de pie, hablar\u2026etc). \" \/><label for=\"quform_6_179_9a10a6_8\" class=\"quform-option-label quform-option-label-6_179_8\"><span class=\"quform-option-text\">Grave (Episodios de somnolencia diario que se dan en situaciones muy activas: Comer,  estar de pie, hablar\u2026etc). <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_180 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_180\"><label class=\"quform-label-text\" id=\"quform_6_180_9a10a6_label\">Somnolencia mientras maneja.  \u00bfPresenta somnolencia mientras maneja?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_180\"><div class=\"quform-input quform-input-radio quform-input-6_180 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_180_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_1\" value=\"No\" \/><label for=\"quform_6_180_9a10a6_1\" class=\"quform-option-label quform-option-label-6_180_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_5\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_5\" value=\"Es raro\" \/><label for=\"quform_6_180_9a10a6_5\" class=\"quform-option-label quform-option-label-6_180_5\"><span class=\"quform-option-text\">Es raro<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_6\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_6\" value=\"Frecuentemente, al medio d\u00eda. \" \/><label for=\"quform_6_180_9a10a6_6\" class=\"quform-option-label quform-option-label-6_180_6\"><span class=\"quform-option-text\">Frecuentemente, al medio d\u00eda. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_8\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_8\" value=\"Frecuentemente, pero no s\u00f3lo al medio d\u00eda. \" \/><label for=\"quform_6_180_9a10a6_8\" class=\"quform-option-label quform-option-label-6_180_8\"><span class=\"quform-option-text\">Frecuentemente, pero no s\u00f3lo al medio d\u00eda. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_9\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_9\" value=\"Siempre, especialmente si son trayectos de m\u00e1s de 30-40 minutos. \" \/><label for=\"quform_6_180_9a10a6_9\" class=\"quform-option-label quform-option-label-6_180_9\"><span class=\"quform-option-text\">Siempre, especialmente si son trayectos de m\u00e1s de 30-40 minutos. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_180\" id=\"quform_6_180_9a10a6_10\" class=\"quform-field quform-field-radio quform-field-6_180 quform-field-6_180_10\" value=\"Siempre, incluso en trayectos menores de 30 minutos.\" \/><label for=\"quform_6_180_9a10a6_10\" class=\"quform-option-label quform-option-label-6_180_10\"><span class=\"quform-option-text\">Siempre, incluso en trayectos menores de 30 minutos.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-6_183 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_181 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Escala de Somnolencia -test- de Epworth<\/strong><\/h4><br \/>\n<span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">El test de Epworth, es una forma de diagn\u00f3stico de presunci\u00f3n, sencilla y objetiva para medir la <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Excesiva Somnolencia Diurna (ESD).<\/b><\/span><\/span><br \/>\n<br \/>\n<span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">Por favor, complete las preguntas en funci\u00f3n de la frecuencia que padece la <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Somnolencia <\/b><\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">en las siguientes situaciones. Si no hubiera realizado recientemente algunas de estas actividades, imagine c\u00f3mo le hubiese afectado la misma.<\/span><\/span><br \/>\n<h6><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">\u00bfQu\u00e9 posibilidad existe de que se quedara dormido\/a o adormilase, en las siguientes situaciones? <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Este test no se refiere a estar cansado.<\/b><\/span><\/span><\/h6><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_182 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_182\"><label class=\"quform-label-text\" id=\"quform_6_182_9a10a6_label\"> Sentado leyendo  <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_182\"><div class=\"quform-input quform-input-radio quform-input-6_182 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_182_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_182\" id=\"quform_6_182_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_182 quform-field-6_182_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_182_9a10a6_1\" class=\"quform-option-label quform-option-label-6_182_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_182\" id=\"quform_6_182_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_182 quform-field-6_182_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_182_9a10a6_2\" class=\"quform-option-label quform-option-label-6_182_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_182\" id=\"quform_6_182_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_182 quform-field-6_182_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_182_9a10a6_3\" class=\"quform-option-label quform-option-label-6_182_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_182\" id=\"quform_6_182_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_182 quform-field-6_182_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_182_9a10a6_4\" class=\"quform-option-label quform-option-label-6_182_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_200 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_200\"><label class=\"quform-label-text\" id=\"quform_6_200_9a10a6_label\">Viendo   la televisi\u00f3n<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_200\"><div class=\"quform-input quform-input-radio quform-input-6_200 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_200_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_200\" id=\"quform_6_200_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_200 quform-field-6_200_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_200_9a10a6_1\" class=\"quform-option-label quform-option-label-6_200_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_200\" id=\"quform_6_200_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_200 quform-field-6_200_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_200_9a10a6_2\" class=\"quform-option-label quform-option-label-6_200_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_200\" id=\"quform_6_200_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_200 quform-field-6_200_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_200_9a10a6_3\" class=\"quform-option-label quform-option-label-6_200_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_200\" id=\"quform_6_200_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_200 quform-field-6_200_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_200_9a10a6_4\" class=\"quform-option-label quform-option-label-6_200_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_201 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_201\"><label class=\"quform-label-text\" id=\"quform_6_201_9a10a6_label\">Sentado inactivo en un lugar p\u00fablico (conferencia, teatro, cine,  reuni\u00f3n social, culto o misa)   <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_201\"><div class=\"quform-input quform-input-radio quform-input-6_201 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_201_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_201\" id=\"quform_6_201_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_201 quform-field-6_201_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_201_9a10a6_1\" class=\"quform-option-label quform-option-label-6_201_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_201\" id=\"quform_6_201_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_201 quform-field-6_201_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_201_9a10a6_2\" class=\"quform-option-label quform-option-label-6_201_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_201\" id=\"quform_6_201_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_201 quform-field-6_201_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_201_9a10a6_3\" class=\"quform-option-label quform-option-label-6_201_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_201\" id=\"quform_6_201_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_201 quform-field-6_201_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_201_9a10a6_4\" class=\"quform-option-label quform-option-label-6_201_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_202 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_202\"><label class=\"quform-label-text\" id=\"quform_6_202_9a10a6_label\">Como pasajero de un carro o autob\u00fas  <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_202\"><div class=\"quform-input quform-input-radio quform-input-6_202 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_202_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_202\" id=\"quform_6_202_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_202 quform-field-6_202_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_202_9a10a6_1\" class=\"quform-option-label quform-option-label-6_202_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_202\" id=\"quform_6_202_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_202 quform-field-6_202_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_202_9a10a6_2\" class=\"quform-option-label quform-option-label-6_202_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_202\" id=\"quform_6_202_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_202 quform-field-6_202_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_202_9a10a6_3\" class=\"quform-option-label quform-option-label-6_202_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_202\" id=\"quform_6_202_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_202 quform-field-6_202_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_202_9a10a6_4\" class=\"quform-option-label quform-option-label-6_202_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_203 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_203\"><label class=\"quform-label-text\" id=\"quform_6_203_9a10a6_label\">Recostado, descansando por la tarde <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_203\"><div class=\"quform-input quform-input-radio quform-input-6_203 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_203_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_203\" id=\"quform_6_203_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_203 quform-field-6_203_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_203_9a10a6_1\" class=\"quform-option-label quform-option-label-6_203_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_203\" id=\"quform_6_203_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_203 quform-field-6_203_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_203_9a10a6_2\" class=\"quform-option-label quform-option-label-6_203_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_203\" id=\"quform_6_203_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_203 quform-field-6_203_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_203_9a10a6_3\" class=\"quform-option-label quform-option-label-6_203_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_203\" id=\"quform_6_203_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_203 quform-field-6_203_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_203_9a10a6_4\" class=\"quform-option-label quform-option-label-6_203_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_204 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_204\"><label class=\"quform-label-text\" id=\"quform_6_204_9a10a6_label\">Sentado,  hablando con otra persona    <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_204\"><div class=\"quform-input quform-input-radio quform-input-6_204 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_204_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_204\" id=\"quform_6_204_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_204 quform-field-6_204_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_204_9a10a6_1\" class=\"quform-option-label quform-option-label-6_204_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_204\" id=\"quform_6_204_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_204 quform-field-6_204_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_204_9a10a6_2\" class=\"quform-option-label quform-option-label-6_204_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_204\" id=\"quform_6_204_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_204 quform-field-6_204_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_204_9a10a6_3\" class=\"quform-option-label quform-option-label-6_204_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_204\" id=\"quform_6_204_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_204 quform-field-6_204_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_204_9a10a6_4\" class=\"quform-option-label quform-option-label-6_204_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_205 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_205\"><label class=\"quform-label-text\" id=\"quform_6_205_9a10a6_label\">Sentado tranquilamente despu\u00e9s de la comida, sin haber tomado alcohol <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_205\"><div class=\"quform-input quform-input-radio quform-input-6_205 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_205_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_205\" id=\"quform_6_205_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_205 quform-field-6_205_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_205_9a10a6_1\" class=\"quform-option-label quform-option-label-6_205_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_205\" id=\"quform_6_205_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_205 quform-field-6_205_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_205_9a10a6_2\" class=\"quform-option-label quform-option-label-6_205_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_205\" id=\"quform_6_205_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_205 quform-field-6_205_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_205_9a10a6_3\" class=\"quform-option-label quform-option-label-6_205_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_205\" id=\"quform_6_205_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_205 quform-field-6_205_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_205_9a10a6_4\" class=\"quform-option-label quform-option-label-6_205_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-6_206 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-6_206\"><label class=\"quform-label-text\" id=\"quform_6_206_9a10a6_label\">Manejando, cuando se detiene unos  minutos por razones de tr\u00e1fico (atasco, cambio del sem\u00e1foro etc.) <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-6_206\"><div class=\"quform-input quform-input-radio quform-input-6_206 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_6_206_9a10a6_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_206\" id=\"quform_6_206_9a10a6_1\" class=\"quform-field quform-field-radio quform-field-6_206 quform-field-6_206_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_6_206_9a10a6_1\" class=\"quform-option-label quform-option-label-6_206_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_206\" id=\"quform_6_206_9a10a6_2\" class=\"quform-field quform-field-radio quform-field-6_206 quform-field-6_206_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_6_206_9a10a6_2\" class=\"quform-option-label quform-option-label-6_206_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_206\" id=\"quform_6_206_9a10a6_3\" class=\"quform-field quform-field-radio quform-field-6_206 quform-field-6_206_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_6_206_9a10a6_3\" class=\"quform-option-label quform-option-label-6_206_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_6_206\" id=\"quform_6_206_9a10a6_4\" class=\"quform-field quform-field-radio quform-field-6_206 quform-field-6_206_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_6_206_9a10a6_4\" class=\"quform-option-label quform-option-label-6_206_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_103 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_103\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-6_103\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-207 quform-page-6_207 quform-cf quform-group-style-plain quform-last-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-6_209 quform-cf\"><div class=\"quform-spacer\"><h3 style=\"text-align: center;\">Muchas gracias por completar el formulario.<\/h3>\n<p style=\"text-align: center;\">Ahora, tan solo debe pulsar sobre el bot\u00f3n <b>SEND <\/b>y esperar a que nos pongamos en contacto con usted para informarle de sus opciones de consulta.<\/p><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-6_208 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-6_208\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-6_208\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">SOLICITAR CONSULTA<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-tree\"><label for=\"quform_6_0_9a10a6\">This field should be left blank<\/label><input type=\"text\" id=\"quform_6_0_9a10a6\" name=\"quform_6_0\" class=\"quform-field quform-field-tree quform-field-6_0\" tabindex=\"-1\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/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-eeb0ea0 elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-shortcode\" data-id=\"eeb0ea0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><iframe id=\"ifrModuloCitaonlineVisualizacion\" src=\"https:\/\/citaonline.dricloud.net\/?URL=dricloud_johanny_20704791\" frameborder=\"0\" scrolling=\"auto\" width=\"100%\" height=\"600\"><\/iframe>\n<\/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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-742fd8b elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"742fd8b\" data-element_type=\"section\" data-e-type=\"section\">\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-2b40f00\" data-id=\"2b40f00\" data-element_type=\"column\" data-e-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-6985dc6 elementor-widget elementor-widget-shortcode\" data-id=\"6985dc6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div id=\"quform-d2e8c1\" class=\"quform quform-1 quform-theme-minimal quform-support-page-caching quform-is-first-page\"><form id=\"quform-form-d2e8c1\" class=\"quform-form quform-form-1\" action=\"\/en\/wp-json\/wp\/v2\/pages\/3084#quform-d2e8c1\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:1,&quot;uniqueId&quot;:&quot;d2e8c1&quot;,&quot;theme&quot;:&quot;minimal&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;45&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;214&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;355&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;341&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Referido por mi m\\u00e9dico&quot;}]},&quot;216&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Presencial en VIDAIR, Santiago de los Caballeros, RD.&quot;}]},&quot;215&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Online, por video-llamada &quot;},{&quot;elementId&quot;:&quot;115&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;3&quot;,&quot;value&quot;:&quot;Llamada telef\\u00f3nica&quot;}]},&quot;98&quot;:{&quot;action&quot;:false,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Neumolog\\u00eda general&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;Fisioterapia Respiratoria (FR)&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Bienestar Nutricional\\u00ae. Sensibilidad alimentaria -microbiota, nutrici\\u00f3n, control de peso, obesidad y entrenamiento F\\u00edsico&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;7&quot;,&quot;value&quot;:&quot;Estudios y pruebas diagnosticas&quot;},{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;8&quot;,&quot;value&quot;:&quot;Experto Health Coach&quot;}]},&quot;217&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Neumolog\\u00eda general&quot;}]},&quot;220&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;219&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;223&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;222&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;225&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;224&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;227&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;226&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;344&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;229&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;345&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;230&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;233&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;232&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;235&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;234&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;237&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;Fisioterapia Respiratoria (FR)&quot;}]},&quot;244&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;243&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;246&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;245&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;347&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;248&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;348&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;249&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;252&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;251&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;254&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;253&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;257&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Bienestar Nutricional\\u00ae. Sensibilidad alimentaria -microbiota, nutrici\\u00f3n, control de peso, obesidad y entrenamiento F\\u00edsico&quot;}]},&quot;263&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;274&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;261&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;260&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;275&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;262&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;349&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;265&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;350&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;266&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;269&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;268&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;271&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;270&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;276&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;7&quot;,&quot;value&quot;:&quot;Estudios y pruebas diagnosticas&quot;}]},&quot;296&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;27&quot;,&quot;value&quot;:&quot;Laboratorio de nutrici\\u00f3n y epigen\\u00e9tica&quot;}]},&quot;297&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Espirometr\\u00eda con test de broncodilataci\\u00f3n &quot;}]},&quot;282&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;297&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;27&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;300&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Polisomnograf\\u00eda (PSG)&quot;}]},&quot;301&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;300&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;27&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;302&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Poligrafia respiratoria (PL)&quot;}]},&quot;303&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;302&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;27&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;304&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;5&quot;,&quot;value&quot;:&quot;Test de marcha de 6 minutos &quot;}]},&quot;305&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;304&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;27&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;306&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;25&quot;,&quot;value&quot;:&quot;Pulsioximetr\\u00eda&quot;}]},&quot;307&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;278&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;26&quot;,&quot;value&quot;:&quot;Prueba de sensibilidad alimentaria&quot;}]},&quot;280&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;279&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;298&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;281&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;284&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;262&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;351&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;286&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;352&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;287&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;290&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;289&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;292&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;291&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;308&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;8&quot;,&quot;value&quot;:&quot;Experto Health Coach&quot;}]},&quot;326&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;281&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;328&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;327&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;14&quot;,&quot;value&quot;:&quot;Otros&quot;}]},&quot;353&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;330&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;354&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;331&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;334&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;333&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;336&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;335&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Si&quot;}]},&quot;99&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;97&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;2&quot;,&quot;value&quot;:&quot;Divisi\\u00f3n Sue\\u00f1o-Salud\\u00ae. Trastornos respiratorios del sue\\u00f1o y trastornos del sue\\u00f1o&quot;}]},&quot;106&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;119&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;108&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;117&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;109&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;117&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;EX FUMADOR\\\/A&quot;}]},&quot;110&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;117&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;4&quot;,&quot;value&quot;:&quot;EX FUMADOR\\\/A&quot;}]},&quot;112&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;118&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;114&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;116&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;126&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;131&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;134&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;133&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;145&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;133&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;161&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;160&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;164&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;162&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;SI&quot;}]},&quot;165&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;164&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;6&quot;,&quot;value&quot;:&quot;Otros&quot;}]}},&quot;dependents&quot;:{&quot;214&quot;:[45],&quot;341&quot;:[355],&quot;115&quot;:[216,215,215],&quot;97&quot;:[98,98,98,98,98,217,237,257,276,308,99],&quot;219&quot;:[220],&quot;222&quot;:[223],&quot;224&quot;:[225],&quot;226&quot;:[227],&quot;229&quot;:[344],&quot;230&quot;:[345],&quot;232&quot;:[233],&quot;234&quot;:[235],&quot;243&quot;:[244],&quot;245&quot;:[246],&quot;248&quot;:[347],&quot;249&quot;:[348],&quot;251&quot;:[252],&quot;253&quot;:[254],&quot;274&quot;:[263],&quot;260&quot;:[261],&quot;262&quot;:[275,284],&quot;265&quot;:[349],&quot;266&quot;:[350],&quot;268&quot;:[269],&quot;270&quot;:[271],&quot;278&quot;:[296,297,300,302,304,306,307],&quot;297&quot;:[282],&quot;300&quot;:[301],&quot;302&quot;:[303],&quot;304&quot;:[305],&quot;279&quot;:[280],&quot;281&quot;:[298,326],&quot;286&quot;:[351],&quot;287&quot;:[352],&quot;289&quot;:[290],&quot;291&quot;:[292],&quot;327&quot;:[328],&quot;330&quot;:[353],&quot;331&quot;:[354],&quot;333&quot;:[334],&quot;335&quot;:[336],&quot;119&quot;:[106],&quot;117&quot;:[108,109,110],&quot;118&quot;:[112],&quot;116&quot;:[114],&quot;131&quot;:[126],&quot;133&quot;:[134,145],&quot;160&quot;:[161],&quot;162&quot;:[164],&quot;164&quot;:[165]},&quot;elementIds&quot;:[45,355,216,215,98,217,220,223,225,227,344,345,233,235,237,244,246,347,348,252,254,257,263,261,275,349,350,269,271,276,296,297,282,300,301,302,303,304,305,306,307,280,298,284,351,352,290,292,308,326,328,353,354,334,336,99,106,108,109,110,112,114,126,134,145,161,164,165],&quot;dependentElementIds&quot;:[&quot;214&quot;,&quot;341&quot;,&quot;115&quot;,&quot;97&quot;,&quot;219&quot;,&quot;222&quot;,&quot;224&quot;,&quot;226&quot;,&quot;229&quot;,&quot;230&quot;,&quot;232&quot;,&quot;234&quot;,&quot;243&quot;,&quot;245&quot;,&quot;248&quot;,&quot;249&quot;,&quot;251&quot;,&quot;253&quot;,&quot;274&quot;,&quot;260&quot;,&quot;262&quot;,&quot;265&quot;,&quot;266&quot;,&quot;268&quot;,&quot;270&quot;,&quot;278&quot;,&quot;297&quot;,&quot;300&quot;,&quot;302&quot;,&quot;304&quot;,&quot;279&quot;,&quot;281&quot;,&quot;286&quot;,&quot;287&quot;,&quot;289&quot;,&quot;291&quot;,&quot;327&quot;,&quot;330&quot;,&quot;331&quot;,&quot;333&quot;,&quot;335&quot;,&quot;119&quot;,&quot;117&quot;,&quot;118&quot;,&quot;116&quot;,&quot;131&quot;,&quot;133&quot;,&quot;160&quot;,&quot;162&quot;,&quot;164&quot;],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:true,&quot;pages&quot;:[1,51,90,217,237,257,276,308,99,207],&quot;pageProgressType&quot;:&quot;percentage&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-1\"><input type=\"hidden\" name=\"quform_form_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"d2e8c1\" \/><input type=\"hidden\" name=\"quform_count\" value=\"2\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/vidairsalud.com\/en\/wp-json\/wp\/v2\/pages\/3084\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"wTyoVJpc9d38CoLk0xlz0kuDLCqJFgPtGJ1GXrex\" \/><div class=\"quform-elements quform-elements-1 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-page-progress quform-page-progress-type-percentage\"><div class=\"quform-page-progress-bar\" style=\"width: 10%;\"><span class=\"quform-page-progress-text\"><span class=\"quform-page-progress-percentage\">10<\/span>%<\/span><\/div><\/div><div class=\"quform-element quform-element-page quform-page-1 quform-page-1_1 quform-cf quform-group-style-plain quform-first-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_7 quform-cf\"><div class=\"quform-spacer\"><h3>DATOS PERSONALES<\/h3><br \/>\nA continuaci\u00f3n le pediremos una serie de datos personales que nos ser\u00e1n de gran utilidad para darle de alta como paciente y poder programar una consulta.<\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_15 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_16\"><div class=\"quform-element quform-element-text quform-element-1_6 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_6\"><label class=\"quform-label-text\" for=\"quform_1_6_d2e8c1\">Nombre y apellidos<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_6\"><div class=\"quform-input quform-input-text quform-input-1_6 quform-cf\"><input type=\"text\" id=\"quform_1_6_d2e8c1\" name=\"quform_1_6\" class=\"quform-field quform-field-text quform-field-1_6\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_17\"><div class=\"quform-element quform-element-text quform-element-1_8 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_8\"><label class=\"quform-label-text\" for=\"quform_1_8_d2e8c1\">Documento de identidad n\u00ba (C\u00e9dula \/ Pasaporte)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_8\"><div class=\"quform-input quform-input-text quform-input-1_8 quform-cf\"><input type=\"text\" id=\"quform_1_8_d2e8c1\" name=\"quform_1_8\" class=\"quform-field quform-field-text quform-field-1_8\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_18 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_19\"><div class=\"quform-element quform-element-text quform-element-1_9 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_9\"><label class=\"quform-label-text\" for=\"quform_1_9_d2e8c1\">Fecha de nacimiento<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_9\"><div class=\"quform-input quform-input-text quform-input-1_9 quform-cf\"><input type=\"text\" id=\"quform_1_9_d2e8c1\" name=\"quform_1_9\" class=\"quform-field quform-field-text quform-field-1_9\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_20\"><div class=\"quform-element quform-element-text quform-element-1_22 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_22\"><label class=\"quform-label-text\" for=\"quform_1_22_d2e8c1\">Edad<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_22\"><div class=\"quform-input quform-input-text quform-input-1_22 quform-cf\"><input type=\"text\" id=\"quform_1_22_d2e8c1\" name=\"quform_1_22\" class=\"quform-field quform-field-text quform-field-1_22\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_23 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_24\"><div class=\"quform-element quform-element-text quform-element-1_25 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_25\"><label class=\"quform-label-text\" for=\"quform_1_25_d2e8c1\">Estado civil<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_25\"><div class=\"quform-input quform-input-text quform-input-1_25 quform-cf\"><input type=\"text\" id=\"quform_1_25_d2e8c1\" name=\"quform_1_25\" class=\"quform-field quform-field-text quform-field-1_25\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_26\"><div class=\"quform-element quform-element-text quform-element-1_27 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_27\"><label class=\"quform-label-text\" for=\"quform_1_27_d2e8c1\">Profesi\u00f3n - oficio<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_27\"><div class=\"quform-input quform-input-text quform-input-1_27 quform-cf\"><input type=\"text\" id=\"quform_1_27_d2e8c1\" name=\"quform_1_27\" class=\"quform-field quform-field-text quform-field-1_27\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_28 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_29\"><div class=\"quform-element quform-element-text quform-element-1_30 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_30\"><label class=\"quform-label-text\" for=\"quform_1_30_d2e8c1\">Direcci\u00f3n<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_30\"><div class=\"quform-input quform-input-text quform-input-1_30 quform-cf\"><input type=\"text\" id=\"quform_1_30_d2e8c1\" name=\"quform_1_30\" class=\"quform-field quform-field-text quform-field-1_30\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_31\"><div class=\"quform-element quform-element-text quform-element-1_32 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_32\"><label class=\"quform-label-text\" for=\"quform_1_32_d2e8c1\">Tel\u00e9fono<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_32\"><div class=\"quform-input quform-input-text quform-input-1_32 quform-cf\"><input type=\"text\" id=\"quform_1_32_d2e8c1\" name=\"quform_1_32\" class=\"quform-field quform-field-text quform-field-1_32\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_33 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_34\"><div class=\"quform-element quform-element-email quform-element-1_38 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_38\"><label class=\"quform-label-text\" for=\"quform_1_38_d2e8c1\">Correo electr\u00f3nico<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-1_38\"><div class=\"quform-input quform-input-email quform-input-1_38 quform-cf\"><input type=\"email\" id=\"quform_1_38_d2e8c1\" name=\"quform_1_38\" class=\"quform-field quform-field-email quform-field-1_38\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_36\"><div class=\"quform-element quform-element-radio quform-element-1_214 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_214\"><label class=\"quform-label-text\" id=\"quform_1_214_d2e8c1_label\">\u00bfAcude a trav\u00e9s de su aseguradora?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_214\"><div class=\"quform-input quform-input-radio quform-input-1_214 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_214_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_214\" id=\"quform_1_214_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_214 quform-field-1_214_1\" value=\"SI\" \/><label for=\"quform_1_214_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_214_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_214\" id=\"quform_1_214_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_214 quform-field-1_214_2\" value=\"NO\" \/><label for=\"quform_1_214_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_214_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_45 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_46 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_47\"><div class=\"quform-element quform-element-select quform-element-1_342 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_342\"><label class=\"quform-label-text\" for=\"quform_1_342_d2e8c1\">Seleccione su aseguradora<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-1_342\"><div class=\"quform-input quform-input-select quform-input-1_342 quform-cf\"><select id=\"quform_1_342_d2e8c1\" name=\"quform_1_342\" class=\"quform-field quform-field-select quform-field-1_342\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Primera ARS de Humano\">Primera ARS de Humano<\/option><option value=\"Humano\">Humano<\/option><option value=\"ARS Universal\">ARS Universal<\/option><option value=\"MAPFRE SALUD ARS\">MAPFRE SALUD ARS<\/option><option value=\"ARS Yunen \">ARS Yunen <\/option><option value=\"ARS MONUMENTAL \">ARS MONUMENTAL <\/option><option value=\"WorldWide Seguros\">WorldWide Seguros<\/option><option value=\"ARS SIMAG\">ARS SIMAG<\/option><option value=\"SERVICIOS MEDICOS UASD\">SERVICIOS MEDICOS UASD<\/option><option value=\"APS ARS\">APS ARS<\/option><option value=\"FUTURO ARS \">FUTURO ARS <\/option><option value=\"MetaSalud ARS\">MetaSalud ARS<\/option><option value=\"ARS ASEMAP\">ARS ASEMAP<\/option><option value=\"SeNaSa Seguro Nacional de Salud.\">SeNaSa Seguro Nacional de Salud.<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_48\"><div class=\"quform-element quform-element-text quform-element-1_49 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_49\"><label class=\"quform-label-text\" for=\"quform_1_49_d2e8c1\">N\u00famero de p\u00f3liza<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_49\"><div class=\"quform-input quform-input-text quform-input-1_49 quform-cf\"><input type=\"text\" id=\"quform_1_49_d2e8c1\" name=\"quform_1_49\" class=\"quform-field quform-field-text quform-field-1_49\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-1_341 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_341\"><label class=\"quform-label-text\" for=\"quform_1_341_d2e8c1\">\u00bfC\u00f3mo ha conocido VIDAIR?<\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-1_341\"><div class=\"quform-input quform-input-select quform-input-1_341 quform-cf\"><select id=\"quform_1_341_d2e8c1\" name=\"quform_1_341\" class=\"quform-field quform-field-select quform-field-1_341\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Referido por mi m\u00e9dico\">Referido por mi m\u00e9dico<\/option><option value=\"Redes sociales\">Redes sociales<\/option><option value=\"Televisi\u00f3n \">Televisi\u00f3n <\/option><option value=\"Radio\">Radio<\/option><option value=\"Prensa\">Prensa<\/option><option value=\"Publicidad en la calle\">Publicidad en la calle<\/option><option value=\"Amigo \/ familiar \">Amigo \/ familiar <\/option><option value=\"Otros\">Otros<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-1_355 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_355\"><label class=\"quform-label-text\" for=\"quform_1_355_d2e8c1\">Seleccione su m\u00e9dico<\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-1_355\"><div class=\"quform-input quform-input-select quform-input-1_355 quform-cf\"><select id=\"quform_1_355_d2e8c1\" name=\"quform_1_355\" class=\"quform-field quform-field-select quform-field-1_355\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Robert Liriano Stambuly\">Robert Liriano Stambuly<\/option><option value=\"Dami\u00e1n Antonio Tavares Robiou\">Dami\u00e1n Antonio Tavares Robiou<\/option><option value=\"Jos\u00e9 Luis Mej\u00eda Vargas\">Jos\u00e9 Luis Mej\u00eda Vargas<\/option><option value=\"Corina Santos Jimenez \">Corina Santos Jimenez <\/option><option value=\"Rosanna Dur\u00e1n Dur\u00e1n \">Rosanna Dur\u00e1n Dur\u00e1n <\/option><option value=\"Lucia Genao \">Lucia Genao <\/option><option value=\"Juan Carlos Marcelino \">Juan Carlos Marcelino <\/option><option value=\"Natalis Tejada Vargas\">Natalis Tejada Vargas<\/option><option value=\"Luis Faringthon Reyes\">Luis Faringthon Reyes<\/option><option value=\"Mayren\u00ed Marte \">Mayren\u00ed Marte <\/option><option value=\"Carlos Manuel Brito Reynoso\">Carlos Manuel Brito Reynoso<\/option><option value=\"Alfa Kenia Fern\u00e1ndez\">Alfa Kenia Fern\u00e1ndez<\/option><option value=\"Angelina Fern\u00e1ndez \">Angelina Fern\u00e1ndez <\/option><option value=\"Amad\u00eds Maldonado \">Amad\u00eds Maldonado <\/option><option value=\"Alexandra Espinal\">Alexandra Espinal<\/option><option value=\"Samuel Hern\u00e1ndez\">Samuel Hern\u00e1ndez<\/option><option value=\"Miguel Adonis Mej\u00eda \">Miguel Adonis Mej\u00eda <\/option><option value=\"Miguel Estrella \">Miguel Estrella <\/option><option value=\"Minerva Espinal \">Minerva Espinal <\/option><option value=\"Elida Mar\u00eda Lantigua Caraballo\">Elida Mar\u00eda Lantigua Caraballo<\/option><option value=\"Katerine Jaqu\u00e9z\">Katerine Jaqu\u00e9z<\/option><option value=\" Victor M\u00e9ndez\"> Victor M\u00e9ndez<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-next quform-button-next-default quform-button-next-1_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-51 quform-page-1_51 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_52 quform-cf\"><div class=\"quform-spacer\"><h3>DETALLES DE LA PROGRAMACI\u00d3N<\/h3><br \/>\nA continuaci\u00f3n le preguntaremos sobre sus preferencias a la hora de agendar una consulta.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_211 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_211\"><label class=\"quform-label-text\" id=\"quform_1_211_d2e8c1_label\">Selecciones el d\u00eda  y la hora de su preferencia para la consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_211\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones.\n\n<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_211 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_211_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_211[]\" id=\"quform_1_211_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_211 quform-field-1_211_1\" value=\"Lunes\" \/><label for=\"quform_1_211_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_211_1\"><span class=\"quform-option-text\">Lunes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_211[]\" id=\"quform_1_211_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_211 quform-field-1_211_2\" value=\"Martes\" \/><label for=\"quform_1_211_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_211_2\"><span class=\"quform-option-text\">Martes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_211[]\" id=\"quform_1_211_d2e8c1_3\" class=\"quform-field quform-field-checkbox quform-field-1_211 quform-field-1_211_3\" value=\"Mi\u00e9rcoles\" \/><label for=\"quform_1_211_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_211_3\"><span class=\"quform-option-text\">Mi\u00e9rcoles<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_211[]\" id=\"quform_1_211_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_211 quform-field-1_211_4\" value=\"Jueves\" \/><label for=\"quform_1_211_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_211_4\"><span class=\"quform-option-text\">Jueves<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_211[]\" id=\"quform_1_211_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_211 quform-field-1_211_5\" value=\"Viernes\" \/><label for=\"quform_1_211_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_211_5\"><span class=\"quform-option-text\">Viernes<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_212 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_212\"><label class=\"quform-label-text\" id=\"quform_1_212_d2e8c1_label\">\u00bfDurante cual tanda desea su cita?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_212\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones.\n\n<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_212 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_212_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_212[]\" id=\"quform_1_212_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_212 quform-field-1_212_1\" value=\"Ma\u00f1ana de 7:30 am a 12:00 m\" \/><label for=\"quform_1_212_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_212_1\"><span class=\"quform-option-text\">Ma\u00f1ana de 7:30 am a 12:00 m<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_212[]\" id=\"quform_1_212_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_212 quform-field-1_212_2\" value=\"Tarde de 1:00 pm a 6:00 pm\" \/><label for=\"quform_1_212_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_212_2\"><span class=\"quform-option-text\">Tarde de 1:00 pm a 6:00 pm<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_212[]\" id=\"quform_1_212_d2e8c1_3\" class=\"quform-field quform-field-checkbox quform-field-1_212 quform-field-1_212_3\" value=\"Noche de 7:00 pm a 8:30 pm\" \/><label for=\"quform_1_212_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_212_3\"><span class=\"quform-option-text\">Noche de 7:00 pm a 8:30 pm<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_115 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_115\"><label class=\"quform-label-text\" id=\"quform_1_115_d2e8c1_label\">\u00bfC\u00f3mo desea realizar su consulta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_115\"><div class=\"quform-input quform-input-radio quform-input-1_115 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_115_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_115\" id=\"quform_1_115_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_115 quform-field-1_115_1\" value=\"Presencial en VIDAIR, Santiago de los Caballeros, RD.\" \/><label for=\"quform_1_115_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_115_1\"><span class=\"quform-option-text\">Presencial en VIDAIR, Santiago de los Caballeros, RD.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_115\" id=\"quform_1_115_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_115 quform-field-1_115_2\" value=\"Online, por video-llamada \" \/><label for=\"quform_1_115_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_115_2\"><span class=\"quform-option-text\">Online, por video-llamada <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_115\" id=\"quform_1_115_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_115 quform-field-1_115_3\" value=\"Llamada telef\u00f3nica\" \/><label for=\"quform_1_115_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_115_3\"><span class=\"quform-option-text\">Llamada telef\u00f3nica<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_216 quform-cf\"><div class=\"quform-spacer\">Recuerde que el uso de la mascarilla es obligatorio todo el tiempo que permanezca dentro de las instalaciones de VIDAIR. Seg\u00fan sea la situaci\u00f3n epidemiol\u00f3gica en la Rep. Dominicana, para las consultas presenciales, por favor, consulte a trav\u00e9s del 0000000000 si es posible acudir acompa\u00f1ado\/a.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_215 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-checkbox quform-inner-1_215\"><div class=\"quform-input quform-input-checkbox quform-input-1_215 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_215[]\" id=\"quform_1_215_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_215 quform-field-1_215_1\" value=\"He recibido por parte de VIDAIR como paciente y\/o familiar o tutor, la advertencia sobre la idoneidad de concertar una cita presencial, y los riesgos e inconvenientes tanto para m\u00ed como paciente, como para el profesional de VIDAIR, de una consulta m\u00e9dica bajo estas circunstancias, no obstante, he decidido concertar mi cita online asumiendo estos riesgos e inconvenientes.   &lt;br \/&gt;Este tipo de consulta, est\u00e1 basado en la informaci\u00f3n que aporta  el paciente y\/o familiar o tutor de forma verbal. Al no ser presencial - v\u00eda telef\u00f3nica, no es posible realizar por parte del\/la m\u00e9dico\/a especialista un examen f\u00edsico que incluya el aspecto general del paciente, los signos cl\u00ednicos que pueda presentar, toma de constantes vitales, ni la realizaci\u00f3n de una exploraci\u00f3n f\u00edsica. Por lo que el juicio diagn\u00f3stico elaborado por el profesional, podr\u00eda no ser concluyente. VIDAIR no se responsabiliza de perjuicios o da\u00f1os de cualquier naturaleza que pudieran presentarse ante la falta de datos cl\u00ednicos, exactitud, autenticidad y\/o exhaustividad de toda la informaci\u00f3n aportada por  el o la paciente, su familiar o tutor legal, para una correcta prestaci\u00f3n del servicio,  y especialmente, por cualquier  da\u00f1o y perjuicio resultado de la suplantaci\u00f3n de personalidad por otra persona, en nombre del o la paciente durante la consulta online, especialmente modo telef\u00f3nica. \" \/><label for=\"quform_1_215_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_215_1\"><span class=\"quform-option-text\">He recibido por parte de VIDAIR como paciente y\/o familiar o tutor, la advertencia sobre la idoneidad de concertar una cita presencial, y los riesgos e inconvenientes tanto para m\u00ed como paciente, como para el profesional de VIDAIR, de una consulta m\u00e9dica bajo estas circunstancias, no obstante, he decidido concertar mi cita online asumiendo estos riesgos e inconvenientes.   <br \/>Este tipo de consulta, est\u00e1 basado en la informaci\u00f3n que aporta  el paciente y\/o familiar o tutor de forma verbal. Al no ser presencial - v\u00eda telef\u00f3nica, no es posible realizar por parte del\/la m\u00e9dico\/a especialista un examen f\u00edsico que incluya el aspecto general del paciente, los signos cl\u00ednicos que pueda presentar, toma de constantes vitales, ni la realizaci\u00f3n de una exploraci\u00f3n f\u00edsica. Por lo que el juicio diagn\u00f3stico elaborado por el profesional, podr\u00eda no ser concluyente. VIDAIR no se responsabiliza de perjuicios o da\u00f1os de cualquier naturaleza que pudieran presentarse ante la falta de datos cl\u00ednicos, exactitud, autenticidad y\/o exhaustividad de toda la informaci\u00f3n aportada por  el o la paciente, su familiar o tutor legal, para una correcta prestaci\u00f3n del servicio,  y especialmente, por cualquier  da\u00f1o y perjuicio resultado de la suplantaci\u00f3n de personalidad por otra persona, en nombre del o la paciente durante la consulta online, especialmente modo telef\u00f3nica. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_85 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_85\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_85\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-90 quform-page-1_90 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_91 quform-cf\"><div class=\"quform-spacer\"><h3>MOTIVO DE SU CONSULTA<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_97 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_97\"><label class=\"quform-label-text\" id=\"quform_1_97_d2e8c1_label\">\u00bfCu\u00e1l es la especialidad en la que desea una consulta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_97\"><div class=\"quform-input quform-input-checkbox quform-input-1_97 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_97_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_1\" value=\"Neumolog\u00eda general\" \/><label for=\"quform_1_97_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_97_1\"><span class=\"quform-option-text\">Neumolog\u00eda general<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_2\" value=\"Divisi\u00f3n Sue\u00f1o-Salud\u00ae. Trastornos respiratorios del sue\u00f1o y trastornos del sue\u00f1o\" \/><label for=\"quform_1_97_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_97_2\"><span class=\"quform-option-text\">Divisi\u00f3n Sue\u00f1o-Salud\u00ae. Trastornos respiratorios del sue\u00f1o y trastornos del sue\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_4\" value=\"Fisioterapia Respiratoria (FR)\" \/><label for=\"quform_1_97_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_97_4\"><span class=\"quform-option-text\">Fisioterapia Respiratoria (FR)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_5\" value=\"Soporte psicol\u00f3gico al paciente respiratorio y familiar o cuidador\" \/><label for=\"quform_1_97_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_97_5\"><span class=\"quform-option-text\">Soporte psicol\u00f3gico al paciente respiratorio y familiar o cuidador<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_6\" value=\"Bienestar Nutricional\u00ae. Sensibilidad alimentaria -microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico\" \/><label for=\"quform_1_97_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_97_6\"><span class=\"quform-option-text\">Bienestar Nutricional\u00ae. Sensibilidad alimentaria -microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_7\" value=\"Estudios y pruebas diagnosticas\" \/><label for=\"quform_1_97_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_97_7\"><span class=\"quform-option-text\">Estudios y pruebas diagnosticas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_8\" value=\"Experto Health Coach\" \/><label for=\"quform_1_97_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_97_8\"><span class=\"quform-option-text\">Experto Health Coach<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_97[]\" id=\"quform_1_97_d2e8c1_9\" class=\"quform-field quform-field-checkbox quform-field-1_97 quform-field-1_97_9\" value=\"No lo s\u00e9 con seguridad\" \/><label for=\"quform_1_97_d2e8c1_9\" class=\"quform-option-label quform-option-label-1_97_9\"><span class=\"quform-option-text\">No lo s\u00e9 con seguridad<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_98 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_98\"><label class=\"quform-label-text\" for=\"quform_1_98_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_98\"><div class=\"quform-input quform-input-textarea quform-input-1_98 quform-cf\"><textarea id=\"quform_1_98_d2e8c1\" name=\"quform_1_98\" class=\"quform-field quform-field-textarea quform-field-1_98\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_95 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_95\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_95\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-217 quform-page-1_217 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_218 quform-cf\"><div class=\"quform-spacer\"><h3>Consulta Neumolog\u00eda general. Cuestionario consulta Neumolog\u00eda.<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_219 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_219\"><label class=\"quform-label-text\" id=\"quform_1_219_d2e8c1_label\">Motivo de consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_219\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_219 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_219_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_1\" value=\"Tos\" \/><label for=\"quform_1_219_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_219_1\"><span class=\"quform-option-text\">Tos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_2\" value=\"Secreci\u00f3n nasal\" \/><label for=\"quform_1_219_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_219_2\"><span class=\"quform-option-text\">Secreci\u00f3n nasal<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_4\" value=\"Estornudos\" \/><label for=\"quform_1_219_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_219_4\"><span class=\"quform-option-text\">Estornudos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_5\" value=\"Obstrucci\u00f3n nasal\" \/><label for=\"quform_1_219_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_219_5\"><span class=\"quform-option-text\">Obstrucci\u00f3n nasal<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_6\" value=\"Expectoraci\u00f3n (mocos)\" \/><label for=\"quform_1_219_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_219_6\"><span class=\"quform-option-text\">Expectoraci\u00f3n (mocos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_7\" value=\"Expectoraci\u00f3n con sangre\" \/><label for=\"quform_1_219_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_219_7\"><span class=\"quform-option-text\">Expectoraci\u00f3n con sangre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_8\" value=\"Fiebre\" \/><label for=\"quform_1_219_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_219_8\"><span class=\"quform-option-text\">Fiebre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_9\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_9\" value=\"Dolor de pecho\" \/><label for=\"quform_1_219_d2e8c1_9\" class=\"quform-option-label quform-option-label-1_219_9\"><span class=\"quform-option-text\">Dolor de pecho<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_10\" value=\"Dificultad respiratoria\" \/><label for=\"quform_1_219_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_219_10\"><span class=\"quform-option-text\">Dificultad respiratoria<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_11\" value=\"Sibilancias (pitos al respirar)\" \/><label for=\"quform_1_219_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_219_11\"><span class=\"quform-option-text\">Sibilancias (pitos al respirar)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_12\" value=\"Ronquido\" \/><label for=\"quform_1_219_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_219_12\"><span class=\"quform-option-text\">Ronquido<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_13\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_13\" value=\"Sospecha de COVID 19\" \/><label for=\"quform_1_219_d2e8c1_13\" class=\"quform-option-label quform-option-label-1_219_13\"><span class=\"quform-option-text\">Sospecha de COVID 19<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_219[]\" id=\"quform_1_219_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_219 quform-field-1_219_14\" value=\"Otros\" \/><label for=\"quform_1_219_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_219_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_220 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_220\"><label class=\"quform-label-text\" for=\"quform_1_220_d2e8c1\">Enumere sus otros s\u00edntomas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_220\"><div class=\"quform-input quform-input-textarea quform-input-1_220 quform-cf\"><textarea id=\"quform_1_220_d2e8c1\" name=\"quform_1_220\" class=\"quform-field quform-field-textarea quform-field-1_220\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_222 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_222\"><label class=\"quform-label-text\" id=\"quform_1_222_d2e8c1_label\">Antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_222\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_222 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_222_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_1\" value=\"Obesidad\" \/><label for=\"quform_1_222_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_222_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_222_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_222_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_222_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_222_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_222_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_222_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_222_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_222_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_7\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_1_222_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_222_7\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_15\" value=\"Enfisema\" \/><label for=\"quform_1_222_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_222_15\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_222_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_222_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_9\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_9\" value=\"Enfermedades autoimunes\" \/><label for=\"quform_1_222_d2e8c1_9\" class=\"quform-option-label quform-option-label-1_222_9\"><span class=\"quform-option-text\">Enfermedades autoimunes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_222_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_222_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_222_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_222_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_222_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_222_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_222[]\" id=\"quform_1_222_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_222 quform-field-1_222_14\" value=\"Otros\" \/><label for=\"quform_1_222_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_222_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_223 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_223\"><label class=\"quform-label-text\" for=\"quform_1_223_d2e8c1\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_223\"><div class=\"quform-input quform-input-textarea quform-input-1_223 quform-cf\"><textarea id=\"quform_1_223_d2e8c1\" name=\"quform_1_223\" class=\"quform-field quform-field-textarea quform-field-1_223\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_224 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_224\"><label class=\"quform-label-text\" id=\"quform_1_224_d2e8c1_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_224\"><div class=\"quform-input quform-input-radio quform-input-1_224 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_224_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_224\" id=\"quform_1_224_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_224 quform-field-1_224_1\" value=\"No\" \/><label for=\"quform_1_224_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_224_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_224\" id=\"quform_1_224_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_224 quform-field-1_224_2\" value=\"Si\" \/><label for=\"quform_1_224_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_224_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_225 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_225\"><label class=\"quform-label-text\" for=\"quform_1_225_d2e8c1\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_225\"><div class=\"quform-input quform-input-text quform-input-1_225 quform-cf\"><input type=\"text\" id=\"quform_1_225_d2e8c1\" name=\"quform_1_225\" class=\"quform-field quform-field-text quform-field-1_225\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_226 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_226\"><label class=\"quform-label-text\" id=\"quform_1_226_d2e8c1_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_226\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_226 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_226_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_1\" value=\"Obesidad\" \/><label for=\"quform_1_226_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_226_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_226_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_226_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_226_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_226_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_226_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_226_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_226_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_226_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_226_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_226_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_226_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_226_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_226_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_226_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_226_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_226_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_226[]\" id=\"quform_1_226_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_226 quform-field-1_226_14\" value=\"Otros\" \/><label for=\"quform_1_226_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_226_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_227 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_227\"><label class=\"quform-label-text\" for=\"quform_1_227_d2e8c1\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_227\"><div class=\"quform-input quform-input-textarea quform-input-1_227 quform-cf\"><textarea id=\"quform_1_227_d2e8c1\" name=\"quform_1_227\" class=\"quform-field quform-field-textarea quform-field-1_227\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_228 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_229 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_229\"><label class=\"quform-label-text\" id=\"quform_1_229_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_229\"><div class=\"quform-input quform-input-radio quform-input-1_229 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_229_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_229\" id=\"quform_1_229_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_229 quform-field-1_229_2\" value=\"Si\" \/><label for=\"quform_1_229_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_229_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_229\" id=\"quform_1_229_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_229 quform-field-1_229_1\" value=\"No\" \/><label for=\"quform_1_229_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_229_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_229\" id=\"quform_1_229_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_229 quform-field-1_229_5\" value=\"Ex fumador\/a\" \/><label for=\"quform_1_229_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_229_5\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_344 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_344\"><label class=\"quform-label-text\" for=\"quform_1_344_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_344\"><div class=\"quform-input quform-input-text quform-input-1_344 quform-cf\"><input type=\"text\" id=\"quform_1_344_d2e8c1\" name=\"quform_1_344\" class=\"quform-field quform-field-text quform-field-1_344\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_230 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_230\"><label class=\"quform-label-text\" id=\"quform_1_230_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_230\"><div class=\"quform-input quform-input-radio quform-input-1_230 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_230_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_230\" id=\"quform_1_230_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_230 quform-field-1_230_2\" value=\"Si\" \/><label for=\"quform_1_230_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_230_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_230\" id=\"quform_1_230_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_230 quform-field-1_230_1\" value=\"No\" \/><label for=\"quform_1_230_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_230_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_345 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_345\"><label class=\"quform-label-text\" for=\"quform_1_345_d2e8c1\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_345\"><div class=\"quform-input quform-input-text quform-input-1_345 quform-cf\"><input type=\"text\" id=\"quform_1_345_d2e8c1\" name=\"quform_1_345\" class=\"quform-field quform-field-text quform-field-1_345\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_231 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_231\"><label class=\"quform-label-text\" id=\"quform_1_231_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_231\"><div class=\"quform-input quform-input-radio quform-input-1_231 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_231_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_231\" id=\"quform_1_231_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_231 quform-field-1_231_2\" value=\"Si\" \/><label for=\"quform_1_231_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_231_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_231\" id=\"quform_1_231_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_231 quform-field-1_231_1\" value=\"No\" \/><label for=\"quform_1_231_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_231_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_232 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_232\"><label class=\"quform-label-text\" id=\"quform_1_232_d2e8c1_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_232\"><div class=\"quform-input quform-input-radio quform-input-1_232 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_232_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_232\" id=\"quform_1_232_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_232 quform-field-1_232_2\" value=\"Si\" \/><label for=\"quform_1_232_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_232_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_232\" id=\"quform_1_232_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_232 quform-field-1_232_1\" value=\"No\" \/><label for=\"quform_1_232_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_232_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_233 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_233\"><label class=\"quform-label-text\" for=\"quform_1_233_d2e8c1\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_233\"><div class=\"quform-input quform-input-text quform-input-1_233 quform-cf\"><input type=\"text\" id=\"quform_1_233_d2e8c1\" name=\"quform_1_233\" class=\"quform-field quform-field-text quform-field-1_233\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_234 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_234\"><label class=\"quform-label-text\" id=\"quform_1_234_d2e8c1_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_234\"><div class=\"quform-input quform-input-radio quform-input-1_234 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_234_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_234\" id=\"quform_1_234_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_234 quform-field-1_234_2\" value=\"Si\" \/><label for=\"quform_1_234_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_234_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_234\" id=\"quform_1_234_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_234 quform-field-1_234_1\" value=\"No\" \/><label for=\"quform_1_234_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_234_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_235 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_235\"><label class=\"quform-label-text\" for=\"quform_1_235_d2e8c1\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_235\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-1_235 quform-cf\"><textarea id=\"quform_1_235_d2e8c1\" name=\"quform_1_235\" class=\"quform-field quform-field-textarea quform-field-1_235\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_236 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_236\"><label class=\"quform-label-text\" for=\"quform_1_236_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_236\"><div class=\"quform-input quform-input-textarea quform-input-1_236 quform-cf\"><textarea id=\"quform_1_236_d2e8c1\" name=\"quform_1_236\" class=\"quform-field quform-field-textarea quform-field-1_236\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_221 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_221\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_221\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-237 quform-page-1_237 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_238 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario consulta Fisioterapia Respiratoria (FR)<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_239 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_239\"><label class=\"quform-label-text\" id=\"quform_1_239_d2e8c1_label\">Motivo o diagn\u00f3stico por el cual se le ha indicado la Fisioterapia Respiratoria:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_239\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_239 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_239_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_1\" value=\"Incapacidad para toser\" \/><label for=\"quform_1_239_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_239_1\"><span class=\"quform-option-text\">Incapacidad para toser<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_2\" value=\"Fibrosis pulmonar\" \/><label for=\"quform_1_239_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_239_2\"><span class=\"quform-option-text\">Fibrosis pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_4\" value=\"Enfisema\" \/><label for=\"quform_1_239_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_239_4\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_5\" value=\"Neumon\u00eda\" \/><label for=\"quform_1_239_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_239_5\"><span class=\"quform-option-text\">Neumon\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_6\" value=\"Neumectom\u00eda\" \/><label for=\"quform_1_239_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_239_6\"><span class=\"quform-option-text\">Neumectom\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_7\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC) exacerbado\" \/><label for=\"quform_1_239_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_239_7\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC) exacerbado<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_8\" value=\"Asma Bronquial\" \/><label for=\"quform_1_239_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_239_8\"><span class=\"quform-option-text\">Asma Bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_9\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_9\" value=\"Neumot\u00f3rax\" \/><label for=\"quform_1_239_d2e8c1_9\" class=\"quform-option-label quform-option-label-1_239_9\"><span class=\"quform-option-text\">Neumot\u00f3rax<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_10\" value=\"Obstrucci\u00f3n bronquial\" \/><label for=\"quform_1_239_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_239_10\"><span class=\"quform-option-text\">Obstrucci\u00f3n bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_11\" value=\"Bronquitis\" \/><label for=\"quform_1_239_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_239_11\"><span class=\"quform-option-text\">Bronquitis<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_12\" value=\"Bronquiectasia\" \/><label for=\"quform_1_239_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_239_12\"><span class=\"quform-option-text\">Bronquiectasia<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_13\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_13\" value=\"Pacientes ventilados\" \/><label for=\"quform_1_239_d2e8c1_13\" class=\"quform-option-label quform-option-label-1_239_13\"><span class=\"quform-option-text\">Pacientes ventilados<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_15\" value=\"Esclerosis Lateral Amiotr\u00f3fica (ELA)\" \/><label for=\"quform_1_239_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_239_15\"><span class=\"quform-option-text\">Esclerosis Lateral Amiotr\u00f3fica (ELA)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_16\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_16\" value=\"Esclerosis m\u00faltiple\" \/><label for=\"quform_1_239_d2e8c1_16\" class=\"quform-option-label quform-option-label-1_239_16\"><span class=\"quform-option-text\">Esclerosis m\u00faltiple<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_17\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_17\" value=\"Miastenia gravis\" \/><label for=\"quform_1_239_d2e8c1_17\" class=\"quform-option-label quform-option-label-1_239_17\"><span class=\"quform-option-text\">Miastenia gravis<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_18\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_18\" value=\"S\u00edndrome de Guillain-Barre\" \/><label for=\"quform_1_239_d2e8c1_18\" class=\"quform-option-label quform-option-label-1_239_18\"><span class=\"quform-option-text\">S\u00edndrome de Guillain-Barre<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_25\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_25\" value=\"Enfisema\" \/><label for=\"quform_1_239_d2e8c1_25\" class=\"quform-option-label quform-option-label-1_239_25\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_19\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_19\" value=\"Fibrosis qu\u00edstica\" \/><label for=\"quform_1_239_d2e8c1_19\" class=\"quform-option-label quform-option-label-1_239_19\"><span class=\"quform-option-text\">Fibrosis qu\u00edstica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_20\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_20\" value=\"Poliomielitis \" \/><label for=\"quform_1_239_d2e8c1_20\" class=\"quform-option-label quform-option-label-1_239_20\"><span class=\"quform-option-text\">Poliomielitis <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_21\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_21\" value=\"Distrofia muscular\" \/><label for=\"quform_1_239_d2e8c1_21\" class=\"quform-option-label quform-option-label-1_239_21\"><span class=\"quform-option-text\">Distrofia muscular<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_22\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_22\" value=\"Atrofia muscular espinal \" \/><label for=\"quform_1_239_d2e8c1_22\" class=\"quform-option-label quform-option-label-1_239_22\"><span class=\"quform-option-text\">Atrofia muscular espinal <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_23\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_23\" value=\"Derrame pleural\" \/><label for=\"quform_1_239_d2e8c1_23\" class=\"quform-option-label quform-option-label-1_239_23\"><span class=\"quform-option-text\">Derrame pleural<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_239[]\" id=\"quform_1_239_d2e8c1_24\" class=\"quform-field quform-field-checkbox quform-field-1_239 quform-field-1_239_24\" value=\"Edema pulmonar\" \/><label for=\"quform_1_239_d2e8c1_24\" class=\"quform-option-label quform-option-label-1_239_24\"><span class=\"quform-option-text\">Edema pulmonar<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_243 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_243\"><label class=\"quform-label-text\" id=\"quform_1_243_d2e8c1_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_243\"><div class=\"quform-input quform-input-radio quform-input-1_243 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_243_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_243\" id=\"quform_1_243_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_243 quform-field-1_243_1\" value=\"No\" \/><label for=\"quform_1_243_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_243_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_243\" id=\"quform_1_243_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_243 quform-field-1_243_2\" value=\"Si\" \/><label for=\"quform_1_243_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_243_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_346 quform-cf\"><div class=\"quform-spacer\"><h4>Antecedentes personales<\/h4><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_244 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_244\"><label class=\"quform-label-text\" for=\"quform_1_244_d2e8c1\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_244\"><div class=\"quform-input quform-input-text quform-input-1_244 quform-cf\"><input type=\"text\" id=\"quform_1_244_d2e8c1\" name=\"quform_1_244\" class=\"quform-field quform-field-text quform-field-1_244\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_245 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_245\"><label class=\"quform-label-text\" id=\"quform_1_245_d2e8c1_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_245\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_245 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_245_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_1\" value=\"Obesidad\" \/><label for=\"quform_1_245_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_245_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_245_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_245_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_245_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_245_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_245_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_245_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_245_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_245_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_245_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_245_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_245_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_245_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_245_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_245_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_245_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_245_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_245_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_245_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_245[]\" id=\"quform_1_245_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_245 quform-field-1_245_14\" value=\"Otros\" \/><label for=\"quform_1_245_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_245_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_246 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_246\"><label class=\"quform-label-text\" for=\"quform_1_246_d2e8c1\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_246\"><div class=\"quform-input quform-input-textarea quform-input-1_246 quform-cf\"><textarea id=\"quform_1_246_d2e8c1\" name=\"quform_1_246\" class=\"quform-field quform-field-textarea quform-field-1_246\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_247 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_248 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_248\"><label class=\"quform-label-text\" id=\"quform_1_248_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_248\"><div class=\"quform-input quform-input-radio quform-input-1_248 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_248_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_248\" id=\"quform_1_248_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_248 quform-field-1_248_2\" value=\"Si\" \/><label for=\"quform_1_248_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_248_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_248\" id=\"quform_1_248_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_248 quform-field-1_248_1\" value=\"No\" \/><label for=\"quform_1_248_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_248_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_248\" id=\"quform_1_248_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_248 quform-field-1_248_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_1_248_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_248_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_347 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_347\"><label class=\"quform-label-text\" for=\"quform_1_347_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_347\"><div class=\"quform-input quform-input-text quform-input-1_347 quform-cf\"><input type=\"text\" id=\"quform_1_347_d2e8c1\" name=\"quform_1_347\" class=\"quform-field quform-field-text quform-field-1_347\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_249 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_249\"><label class=\"quform-label-text\" id=\"quform_1_249_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_249\"><div class=\"quform-input quform-input-radio quform-input-1_249 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_249_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_249\" id=\"quform_1_249_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_249 quform-field-1_249_2\" value=\"Si\" \/><label for=\"quform_1_249_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_249_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_249\" id=\"quform_1_249_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_249 quform-field-1_249_1\" value=\"No\" \/><label for=\"quform_1_249_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_249_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_348 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_348\"><label class=\"quform-label-text\" for=\"quform_1_348_d2e8c1\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_348\"><div class=\"quform-input quform-input-text quform-input-1_348 quform-cf\"><input type=\"text\" id=\"quform_1_348_d2e8c1\" name=\"quform_1_348\" class=\"quform-field quform-field-text quform-field-1_348\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_250 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_250\"><label class=\"quform-label-text\" id=\"quform_1_250_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_250\"><div class=\"quform-input quform-input-radio quform-input-1_250 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_250_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_250\" id=\"quform_1_250_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_250 quform-field-1_250_2\" value=\"Si\" \/><label for=\"quform_1_250_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_250_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_250\" id=\"quform_1_250_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_250 quform-field-1_250_1\" value=\"No\" \/><label for=\"quform_1_250_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_250_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_251 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_251\"><label class=\"quform-label-text\" id=\"quform_1_251_d2e8c1_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_251\"><div class=\"quform-input quform-input-radio quform-input-1_251 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_251_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_251\" id=\"quform_1_251_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_251 quform-field-1_251_2\" value=\"Si\" \/><label for=\"quform_1_251_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_251_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_251\" id=\"quform_1_251_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_251 quform-field-1_251_1\" value=\"No\" \/><label for=\"quform_1_251_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_251_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_252 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_252\"><label class=\"quform-label-text\" for=\"quform_1_252_d2e8c1\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_252\"><div class=\"quform-input quform-input-text quform-input-1_252 quform-cf\"><input type=\"text\" id=\"quform_1_252_d2e8c1\" name=\"quform_1_252\" class=\"quform-field quform-field-text quform-field-1_252\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_253 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_253\"><label class=\"quform-label-text\" id=\"quform_1_253_d2e8c1_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_253\"><div class=\"quform-input quform-input-radio quform-input-1_253 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_253_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_253\" id=\"quform_1_253_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_253 quform-field-1_253_2\" value=\"Si\" \/><label for=\"quform_1_253_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_253_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_253\" id=\"quform_1_253_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_253 quform-field-1_253_1\" value=\"No\" \/><label for=\"quform_1_253_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_253_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_254 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_254\"><label class=\"quform-label-text\" for=\"quform_1_254_d2e8c1\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_254\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-1_254 quform-cf\"><textarea id=\"quform_1_254_d2e8c1\" name=\"quform_1_254\" class=\"quform-field quform-field-textarea quform-field-1_254\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_255 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_255\"><label class=\"quform-label-text\" for=\"quform_1_255_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_255\"><div class=\"quform-input quform-input-textarea quform-input-1_255 quform-cf\"><textarea id=\"quform_1_255_d2e8c1\" name=\"quform_1_255\" class=\"quform-field quform-field-textarea quform-field-1_255\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_256 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_256\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_256\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-257 quform-page-1_257 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_258 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario consulta VIDAIR Bienestar Nutricional\u00ae:  sensibilidad alimentaria - microbiota, nutrici\u00f3n, control de peso, obesidad y entrenamiento F\u00edsico. <\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_259 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_259\"><label class=\"quform-label-text\" id=\"quform_1_259_d2e8c1_label\">Motivo de consulta<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_259\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_259 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_259_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_1\" value=\"Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Bajo peso.\" \/><label for=\"quform_1_259_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_259_1\"><span class=\"quform-option-text\">Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Bajo peso.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_2\" value=\"Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas. \" \/><label for=\"quform_1_259_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_259_2\"><span class=\"quform-option-text\">Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_4\" value=\"Sistema nervioso: Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza.\" \/><label for=\"quform_1_259_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_259_4\"><span class=\"quform-option-text\">Sistema nervioso: Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_5\" value=\"Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes.\" \/><label for=\"quform_1_259_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_259_5\"><span class=\"quform-option-text\">Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_6\" value=\"Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.\" \/><label for=\"quform_1_259_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_259_6\"><span class=\"quform-option-text\">Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_259[]\" id=\"quform_1_259_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_259 quform-field-1_259_7\" value=\"Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. Fibromialgia. Otras enfermedades autoinmunes. \" \/><label for=\"quform_1_259_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_259_7\"><span class=\"quform-option-text\">Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. Fibromialgia. Otras enfermedades autoinmunes. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_274 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_274\"><label class=\"quform-label-text\" id=\"quform_1_274_d2e8c1_label\">Antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_274\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_274 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_274_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_1\" value=\"Obesidad\" \/><label for=\"quform_1_274_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_274_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_274_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_274_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_274_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_274_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_274_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_274_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_274_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_274_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_274_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_274_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_16\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_16\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_1_274_d2e8c1_16\" class=\"quform-option-label quform-option-label-1_274_16\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_17\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_17\" value=\"Enfisema\" \/><label for=\"quform_1_274_d2e8c1_17\" class=\"quform-option-label quform-option-label-1_274_17\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_274_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_274_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_274_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_274_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_274_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_274_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_274_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_274_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_274[]\" id=\"quform_1_274_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_274 quform-field-1_274_14\" value=\"Otros\" \/><label for=\"quform_1_274_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_274_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_263 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_263\"><label class=\"quform-label-text\" for=\"quform_1_263_d2e8c1\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_263\"><div class=\"quform-input quform-input-textarea quform-input-1_263 quform-cf\"><textarea id=\"quform_1_263_d2e8c1\" name=\"quform_1_263\" class=\"quform-field quform-field-textarea quform-field-1_263\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_260 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_260\"><label class=\"quform-label-text\" id=\"quform_1_260_d2e8c1_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_260\"><div class=\"quform-input quform-input-radio quform-input-1_260 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_260_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_260\" id=\"quform_1_260_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_260 quform-field-1_260_1\" value=\"No\" \/><label for=\"quform_1_260_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_260_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_260\" id=\"quform_1_260_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_260 quform-field-1_260_2\" value=\"Si\" \/><label for=\"quform_1_260_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_260_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_261 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_261\"><label class=\"quform-label-text\" for=\"quform_1_261_d2e8c1\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_261\"><div class=\"quform-input quform-input-text quform-input-1_261 quform-cf\"><input type=\"text\" id=\"quform_1_261_d2e8c1\" name=\"quform_1_261\" class=\"quform-field quform-field-text quform-field-1_261\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_262 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_262\"><label class=\"quform-label-text\" id=\"quform_1_262_d2e8c1_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_262\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_262 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_262_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_1\" value=\"Obesidad\" \/><label for=\"quform_1_262_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_262_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_262_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_262_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_262_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_262_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_262_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_262_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_262_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_262_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_262_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_262_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_262_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_262_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_262_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_262_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_262_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_262_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_262_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_262_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_262[]\" id=\"quform_1_262_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_262 quform-field-1_262_14\" value=\"Otros\" \/><label for=\"quform_1_262_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_262_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_275 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_275\"><label class=\"quform-label-text\" for=\"quform_1_275_d2e8c1\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_275\"><div class=\"quform-input quform-input-textarea quform-input-1_275 quform-cf\"><textarea id=\"quform_1_275_d2e8c1\" name=\"quform_1_275\" class=\"quform-field quform-field-textarea quform-field-1_275\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_264 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_265 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_265\"><label class=\"quform-label-text\" id=\"quform_1_265_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_265\"><div class=\"quform-input quform-input-radio quform-input-1_265 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_265_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_265\" id=\"quform_1_265_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_265 quform-field-1_265_2\" value=\"Si\" \/><label for=\"quform_1_265_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_265_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_265\" id=\"quform_1_265_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_265 quform-field-1_265_1\" value=\"No\" \/><label for=\"quform_1_265_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_265_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_265\" id=\"quform_1_265_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_265 quform-field-1_265_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_1_265_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_265_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_349 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_349\"><label class=\"quform-label-text\" for=\"quform_1_349_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_349\"><div class=\"quform-input quform-input-text quform-input-1_349 quform-cf\"><input type=\"text\" id=\"quform_1_349_d2e8c1\" name=\"quform_1_349\" class=\"quform-field quform-field-text quform-field-1_349\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_266 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_266\"><label class=\"quform-label-text\" id=\"quform_1_266_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_266\"><div class=\"quform-input quform-input-radio quform-input-1_266 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_266_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_266\" id=\"quform_1_266_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_266 quform-field-1_266_2\" value=\"Si\" \/><label for=\"quform_1_266_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_266_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_266\" id=\"quform_1_266_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_266 quform-field-1_266_1\" value=\"No\" \/><label for=\"quform_1_266_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_266_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_350 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_350\"><label class=\"quform-label-text\" for=\"quform_1_350_d2e8c1\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_350\"><div class=\"quform-input quform-input-text quform-input-1_350 quform-cf\"><input type=\"text\" id=\"quform_1_350_d2e8c1\" name=\"quform_1_350\" class=\"quform-field quform-field-text quform-field-1_350\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_267 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_267\"><label class=\"quform-label-text\" id=\"quform_1_267_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_267\"><div class=\"quform-input quform-input-radio quform-input-1_267 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_267_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_267\" id=\"quform_1_267_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_267 quform-field-1_267_2\" value=\"Si\" \/><label for=\"quform_1_267_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_267_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_267\" id=\"quform_1_267_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_267 quform-field-1_267_1\" value=\"No\" \/><label for=\"quform_1_267_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_267_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_268 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_268\"><label class=\"quform-label-text\" id=\"quform_1_268_d2e8c1_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_268\"><div class=\"quform-input quform-input-radio quform-input-1_268 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_268_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_268\" id=\"quform_1_268_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_268 quform-field-1_268_2\" value=\"Si\" \/><label for=\"quform_1_268_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_268_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_268\" id=\"quform_1_268_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_268 quform-field-1_268_1\" value=\"No\" \/><label for=\"quform_1_268_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_268_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_269 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_269\"><label class=\"quform-label-text\" for=\"quform_1_269_d2e8c1\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_269\"><div class=\"quform-input quform-input-text quform-input-1_269 quform-cf\"><input type=\"text\" id=\"quform_1_269_d2e8c1\" name=\"quform_1_269\" class=\"quform-field quform-field-text quform-field-1_269\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_270 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_270\"><label class=\"quform-label-text\" id=\"quform_1_270_d2e8c1_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_270\"><div class=\"quform-input quform-input-radio quform-input-1_270 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_270_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_270\" id=\"quform_1_270_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_270 quform-field-1_270_2\" value=\"Si\" \/><label for=\"quform_1_270_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_270_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_270\" id=\"quform_1_270_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_270 quform-field-1_270_1\" value=\"No\" \/><label for=\"quform_1_270_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_270_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_271 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_271\"><label class=\"quform-label-text\" for=\"quform_1_271_d2e8c1\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_271\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-1_271 quform-cf\"><textarea id=\"quform_1_271_d2e8c1\" name=\"quform_1_271\" class=\"quform-field quform-field-textarea quform-field-1_271\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_272 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_272\"><label class=\"quform-label-text\" for=\"quform_1_272_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_272\"><div class=\"quform-input quform-input-textarea quform-input-1_272 quform-cf\"><textarea id=\"quform_1_272_d2e8c1\" name=\"quform_1_272\" class=\"quform-field quform-field-textarea quform-field-1_272\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_273 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_273\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_273\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-276 quform-page-1_276 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_277 quform-cf\"><div class=\"quform-spacer\"><h3>CUESTIONARIOS PARA ESTUDIOS Y PRUEBAS DIAGN\u00d3STICAS<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_278 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_278\"><label class=\"quform-label-text\" id=\"quform_1_278_d2e8c1_label\">Seleccione la prueba diagn\u00f3stica que desea realizar en VIDAIR<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_278\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_278 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_278_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_1\" value=\"Polisomnograf\u00eda (PSG)\" \/><label for=\"quform_1_278_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_278_1\"><span class=\"quform-option-text\">Polisomnograf\u00eda (PSG)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_2\" value=\"Poligrafia respiratoria (PL)\" \/><label for=\"quform_1_278_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_278_2\"><span class=\"quform-option-text\">Poligrafia respiratoria (PL)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_4\" value=\"Capnograf\u00eda\" \/><label for=\"quform_1_278_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_278_4\"><span class=\"quform-option-text\">Capnograf\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_5\" value=\"Test de marcha de 6 minutos \" \/><label for=\"quform_1_278_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_278_5\"><span class=\"quform-option-text\">Test de marcha de 6 minutos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_6\" value=\"Espirometr\u00eda con test de broncodilataci\u00f3n \" \/><label for=\"quform_1_278_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_278_6\"><span class=\"quform-option-text\">Espirometr\u00eda con test de broncodilataci\u00f3n <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_7\" value=\"Titulaci\u00f3n y\/o monitorizaci\u00f3n con CPAP\" \/><label for=\"quform_1_278_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_278_7\"><span class=\"quform-option-text\">Titulaci\u00f3n y\/o monitorizaci\u00f3n con CPAP<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_25\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_25\" value=\"Pulsioximetr\u00eda\" \/><label for=\"quform_1_278_d2e8c1_25\" class=\"quform-option-label quform-option-label-1_278_25\"><span class=\"quform-option-text\">Pulsioximetr\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_26\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_26\" value=\"Prueba de sensibilidad alimentaria\" \/><label for=\"quform_1_278_d2e8c1_26\" class=\"quform-option-label quform-option-label-1_278_26\"><span class=\"quform-option-text\">Prueba de sensibilidad alimentaria<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_278[]\" id=\"quform_1_278_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_278 quform-field-1_278_27\" value=\"Laboratorio de nutrici\u00f3n y epigen\u00e9tica\" \/><label for=\"quform_1_278_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_278_27\"><span class=\"quform-option-text\">Laboratorio de nutrici\u00f3n y epigen\u00e9tica<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_296 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_296\"><label class=\"quform-label-text\" id=\"quform_1_296_d2e8c1_label\">LABORATORIO NUTRICI\u00d3N y EPIGEN\u00c9TICA<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_296\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_296 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_296_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_1\" value=\"Sensibilidad alimentaria IgG\" \/><label for=\"quform_1_296_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_296_1\"><span class=\"quform-option-text\">Sensibilidad alimentaria IgG<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_2\" value=\"Secreci\u00f3n de melatonina\" \/><label for=\"quform_1_296_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_296_2\"><span class=\"quform-option-text\">Secreci\u00f3n de melatonina<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_4\" value=\"Alergias alimentarias IgE\" \/><label for=\"quform_1_296_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_296_4\"><span class=\"quform-option-text\">Alergias alimentarias IgE<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_5\" value=\"Gen\u00e9tica de gluten \u2013 Gen HLA-DQ cel\u00edaco o celiaqu\u00eda\" \/><label for=\"quform_1_296_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_296_5\"><span class=\"quform-option-text\">Gen\u00e9tica de gluten \u2013 Gen HLA-DQ cel\u00edaco o celiaqu\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_6\" value=\"Gastrointestinal (microrganismos pat\u00f3genos, beneficioso, marcadores inflamat\u00f3rios,)\" \/><label for=\"quform_1_296_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_296_6\"><span class=\"quform-option-text\">Gastrointestinal (microrganismos pat\u00f3genos, beneficioso, marcadores inflamat\u00f3rios,)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_7\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_7\" value=\" Infecciones (c\u00e1ndida y otros organismos pat\u00f3genos)\" \/><label for=\"quform_1_296_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_296_7\"><span class=\"quform-option-text\"> Infecciones (c\u00e1ndida y otros organismos pat\u00f3genos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_25\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_25\" value=\"\u00c1cidos org\u00e1nicos (mide deficiencia de detoxificaci\u00f3n, antioxidantes y microorganismos)\" \/><label for=\"quform_1_296_d2e8c1_25\" class=\"quform-option-label quform-option-label-1_296_25\"><span class=\"quform-option-text\">\u00c1cidos org\u00e1nicos (mide deficiencia de detoxificaci\u00f3n, antioxidantes y microorganismos)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_26\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_26\" value=\"Metales pesados (presencia y toxicidad por metales pesados en el organismo.\" \/><label for=\"quform_1_296_d2e8c1_26\" class=\"quform-option-label quform-option-label-1_296_26\"><span class=\"quform-option-text\">Metales pesados (presencia y toxicidad por metales pesados en el organismo.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_27\" value=\"Vitaminas y minerales ( mide micronutrientes a nivel celular, que es m\u00e1s efectivo que a nivel  sangu\u00edneo)\" \/><label for=\"quform_1_296_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_296_27\"><span class=\"quform-option-text\">Vitaminas y minerales ( mide micronutrientes a nivel celular, que es m\u00e1s efectivo que a nivel  sangu\u00edneo)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_28\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_28\" value=\"Epigen\u00e9tica (variaciones gen\u00e9ticas que influyen en la salud o enfermedad, incluyendo la  metilaci\u00f3n)\" \/><label for=\"quform_1_296_d2e8c1_28\" class=\"quform-option-label quform-option-label-1_296_28\"><span class=\"quform-option-text\">Epigen\u00e9tica (variaciones gen\u00e9ticas que influyen en la salud o enfermedad, incluyendo la  metilaci\u00f3n)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_29\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_29\" value=\"Hormonas (an\u00e1lisis de hormonas adrenales y sexuales)\" \/><label for=\"quform_1_296_d2e8c1_29\" class=\"quform-option-label quform-option-label-1_296_29\"><span class=\"quform-option-text\">Hormonas (an\u00e1lisis de hormonas adrenales y sexuales)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_30\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_30\" value=\"Neurotransmisores (neurotransmisores que influyen en el comportamiento humano)\" \/><label for=\"quform_1_296_d2e8c1_30\" class=\"quform-option-label quform-option-label-1_296_30\"><span class=\"quform-option-text\">Neurotransmisores (neurotransmisores que influyen en el comportamiento humano)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_296[]\" id=\"quform_1_296_d2e8c1_31\" class=\"quform-field quform-field-checkbox quform-field-1_296 quform-field-1_296_31\" value=\"PANDAS (pedi\u00e1trico, neuropsiqui\u00e1trico associado com Streptococcus)\" \/><label for=\"quform_1_296_d2e8c1_31\" class=\"quform-option-label quform-option-label-1_296_31\"><span class=\"quform-option-text\">PANDAS (pedi\u00e1trico, neuropsiqui\u00e1trico associado com Streptococcus)<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_297 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_297\"><label class=\"quform-label-text\" id=\"quform_1_297_d2e8c1_label\"><b>Espirometr\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_297\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_297 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_297_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_1\" value=\"Asma bronquial\" \/><label for=\"quform_1_297_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_297_1\"><span class=\"quform-option-text\">Asma bronquial<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_2\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC)\" \/><label for=\"quform_1_297_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_297_2\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica (EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_4\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_1_297_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_297_4\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_5\" value=\"Enfisema\" \/><label for=\"quform_1_297_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_297_5\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_6\" value=\"Fibrosis pulmonar\" \/><label for=\"quform_1_297_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_297_6\"><span class=\"quform-option-text\">Fibrosis pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_297[]\" id=\"quform_1_297_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_297 quform-field-1_297_27\" value=\"Otros\" \/><label for=\"quform_1_297_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_297_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_282 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_282\"><label class=\"quform-label-text\" for=\"quform_1_282_d2e8c1\">Enumere el resto de motivos por los que se le ha indicado realizar una Espirometr\u00eda<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_282\"><div class=\"quform-input quform-input-text quform-input-1_282 quform-cf\"><input type=\"text\" id=\"quform_1_282_d2e8c1\" name=\"quform_1_282\" class=\"quform-field quform-field-text quform-field-1_282\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_300 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_300\"><label class=\"quform-label-text\" id=\"quform_1_300_d2e8c1_label\"><b>Polisomnograf\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_300\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_300 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_300_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_1\" value=\"Apnea Obstructiva del Sue\u00f1o (AOS)\" \/><label for=\"quform_1_300_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_300_1\"><span class=\"quform-option-text\">Apnea Obstructiva del Sue\u00f1o (AOS)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_2\" value=\"S\u00edndrome de movimientos peri\u00f3dicos de las piernas\" \/><label for=\"quform_1_300_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_300_2\"><span class=\"quform-option-text\">S\u00edndrome de movimientos peri\u00f3dicos de las piernas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_4\" value=\"Narcolepsia \" \/><label for=\"quform_1_300_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_300_4\"><span class=\"quform-option-text\">Narcolepsia <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_5\" value=\"Conductas inusuales durante el sue\u00f1o\" \/><label for=\"quform_1_300_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_300_5\"><span class=\"quform-option-text\">Conductas inusuales durante el sue\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_6\" value=\"Insomnio cr\u00f3nico sin causa aparente\" \/><label for=\"quform_1_300_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_300_6\"><span class=\"quform-option-text\">Insomnio cr\u00f3nico sin causa aparente<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_28\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_28\" value=\"Trastorno de conducta del sue\u00f1o con movimientos oculares r\u00e1pidos\" \/><label for=\"quform_1_300_d2e8c1_28\" class=\"quform-option-label quform-option-label-1_300_28\"><span class=\"quform-option-text\">Trastorno de conducta del sue\u00f1o con movimientos oculares r\u00e1pidos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_300[]\" id=\"quform_1_300_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_300 quform-field-1_300_27\" value=\"Otros\" \/><label for=\"quform_1_300_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_300_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_301 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_301\"><label class=\"quform-label-text\" for=\"quform_1_301_d2e8c1\">Enumere el resto de motivos por los que se le ha indicado realizar una Polisomnograf\u00eda <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_301\"><div class=\"quform-input quform-input-text quform-input-1_301 quform-cf\"><input type=\"text\" id=\"quform_1_301_d2e8c1\" name=\"quform_1_301\" class=\"quform-field quform-field-text quform-field-1_301\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_302 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_302\"><label class=\"quform-label-text\" id=\"quform_1_302_d2e8c1_label\"><b>Poligrafia Respiratoria<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_302\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_302 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_302_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_302[]\" id=\"quform_1_302_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_302 quform-field-1_302_1\" value=\"Ronquidos. Sospecha Apnea Obstructiva del sue\u00f1o (AOS)\" \/><label for=\"quform_1_302_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_302_1\"><span class=\"quform-option-text\">Ronquidos. Sospecha Apnea Obstructiva del sue\u00f1o (AOS)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_302[]\" id=\"quform_1_302_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_302 quform-field-1_302_27\" value=\"Otros\" \/><label for=\"quform_1_302_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_302_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_303 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_303\"><label class=\"quform-label-text\" for=\"quform_1_303_d2e8c1\">Enumere el resto de motivos por los que se le ha indicado realizar una Poligrafia Respiratoria<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_303\"><div class=\"quform-input quform-input-text quform-input-1_303 quform-cf\"><input type=\"text\" id=\"quform_1_303_d2e8c1\" name=\"quform_1_303\" class=\"quform-field quform-field-text quform-field-1_303\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_304 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_304\"><label class=\"quform-label-text\" id=\"quform_1_304_d2e8c1_label\"><b>Test de marcha de 6 minutos<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_304\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_304 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_304_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_304[]\" id=\"quform_1_304_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_304 quform-field-1_304_1\" value=\"Hipertensi\u00f3n pulmonar\" \/><label for=\"quform_1_304_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_304_1\"><span class=\"quform-option-text\">Hipertensi\u00f3n pulmonar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_304[]\" id=\"quform_1_304_d2e8c1_29\" class=\"quform-field quform-field-checkbox quform-field-1_304 quform-field-1_304_29\" value=\"Insuficiencia cardiaca\" \/><label for=\"quform_1_304_d2e8c1_29\" class=\"quform-option-label quform-option-label-1_304_29\"><span class=\"quform-option-text\">Insuficiencia cardiaca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_304[]\" id=\"quform_1_304_d2e8c1_30\" class=\"quform-field quform-field-checkbox quform-field-1_304 quform-field-1_304_30\" value=\"Enfermedad Obstructiva Cr\u00f3nica (EPOC)\" \/><label for=\"quform_1_304_d2e8c1_30\" class=\"quform-option-label quform-option-label-1_304_30\"><span class=\"quform-option-text\">Enfermedad Obstructiva Cr\u00f3nica (EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_304[]\" id=\"quform_1_304_d2e8c1_31\" class=\"quform-field quform-field-checkbox quform-field-1_304 quform-field-1_304_31\" value=\"Fibrosis Pulmonar \" \/><label for=\"quform_1_304_d2e8c1_31\" class=\"quform-option-label quform-option-label-1_304_31\"><span class=\"quform-option-text\">Fibrosis Pulmonar <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_304[]\" id=\"quform_1_304_d2e8c1_27\" class=\"quform-field quform-field-checkbox quform-field-1_304 quform-field-1_304_27\" value=\"Otros\" \/><label for=\"quform_1_304_d2e8c1_27\" class=\"quform-option-label quform-option-label-1_304_27\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_305 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_305\"><label class=\"quform-label-text\" for=\"quform_1_305_d2e8c1\">Enumere el resto de motivos por los que se le ha indicado realizar un Test de marcha de 6 minutos <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_305\"><div class=\"quform-input quform-input-text quform-input-1_305 quform-cf\"><input type=\"text\" id=\"quform_1_305_d2e8c1\" name=\"quform_1_305\" class=\"quform-field quform-field-text quform-field-1_305\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_306 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_306\"><label class=\"quform-label-text\" id=\"quform_1_306_d2e8c1_label\"><b>Pulsioximetr\u00eda<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_306\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_306 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_306_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_306[]\" id=\"quform_1_306_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_306 quform-field-1_306_1\" value=\"Enfermedad Pulmonar Obstructiva Cr\u00f3nica EPOC)\" \/><label for=\"quform_1_306_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_306_1\"><span class=\"quform-option-text\">Enfermedad Pulmonar Obstructiva Cr\u00f3nica EPOC)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_306[]\" id=\"quform_1_306_d2e8c1_29\" class=\"quform-field quform-field-checkbox quform-field-1_306 quform-field-1_306_29\" value=\"Asma Bronquial \" \/><label for=\"quform_1_306_d2e8c1_29\" class=\"quform-option-label quform-option-label-1_306_29\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_306[]\" id=\"quform_1_306_d2e8c1_30\" class=\"quform-field quform-field-checkbox quform-field-1_306 quform-field-1_306_30\" value=\"Infecci\u00f3n respiratoria aguda (neumon\u00eda, influenza, infecciones respiratoria relacionada con SIDA)\" \/><label for=\"quform_1_306_d2e8c1_30\" class=\"quform-option-label quform-option-label-1_306_30\"><span class=\"quform-option-text\">Infecci\u00f3n respiratoria aguda (neumon\u00eda, influenza, infecciones respiratoria relacionada con SIDA)<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_306[]\" id=\"quform_1_306_d2e8c1_31\" class=\"quform-field quform-field-checkbox quform-field-1_306 quform-field-1_306_31\" value=\"COVID 19\" \/><label for=\"quform_1_306_d2e8c1_31\" class=\"quform-option-label quform-option-label-1_306_31\"><span class=\"quform-option-text\">COVID 19<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_307 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_307\"><label class=\"quform-label-text\" id=\"quform_1_307_d2e8c1_label\"><b>Prueba de sensibilidad alimentaria<\/b>. Motivo o diagn\u00f3stico por el cual se le indica<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_307\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_307 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_307_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_307[]\" id=\"quform_1_307_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_307 quform-field-1_307_1\" value=\"Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas.\" \/><label for=\"quform_1_307_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_307_1\"><span class=\"quform-option-text\">Piel: Eczema. Urticaria. Picor. Dermatitis. Acn\u00e9. Manchas.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_307[]\" id=\"quform_1_307_d2e8c1_29\" class=\"quform-field quform-field-checkbox quform-field-1_307 quform-field-1_307_29\" value=\"Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes. \" \/><label for=\"quform_1_307_d2e8c1_29\" class=\"quform-option-label quform-option-label-1_307_29\"><span class=\"quform-option-text\">Respiratorio: Rinitis. Tos. Bronquitis. Asma Bronquial. Secreciones constantes. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_307[]\" id=\"quform_1_307_d2e8c1_30\" class=\"quform-field quform-field-checkbox quform-field-1_307 quform-field-1_307_30\" value=\"Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.\" \/><label for=\"quform_1_307_d2e8c1_30\" class=\"quform-option-label quform-option-label-1_307_30\"><span class=\"quform-option-text\">Digestivo: Sensaci\u00f3n de hinchaz\u00f3n. Distensi\u00f3n abdominal. Digestiones pesadas. Eructos. Flatulencia. Ardor estomacal.  Estre\u00f1imiento. Diarrea. Aftas orales. Colon irritable.<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_307[]\" id=\"quform_1_307_d2e8c1_32\" class=\"quform-field quform-field-checkbox quform-field-1_307 quform-field-1_307_32\" value=\"Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. \" \/><label for=\"quform_1_307_d2e8c1_32\" class=\"quform-option-label quform-option-label-1_307_32\"><span class=\"quform-option-text\">Articulaciones: Rigidez. Dolor. Inflamaci\u00f3n. Artritis. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_307[]\" id=\"quform_1_307_d2e8c1_31\" class=\"quform-field quform-field-checkbox quform-field-1_307 quform-field-1_307_31\" value=\"Otros: Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Fibromialgia. Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza. \" \/><label for=\"quform_1_307_d2e8c1_31\" class=\"quform-option-label quform-option-label-1_307_31\"><span class=\"quform-option-text\">Otros: Sobrepeso. Obesidad. Retenci\u00f3n de l\u00edquidos. Fibromialgia. Depresi\u00f3n. Ansiedad.  Hiperactividad. Dolor de cabeza. <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_299 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes personales<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_279 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_279\"><label class=\"quform-label-text\" id=\"quform_1_279_d2e8c1_label\">Ha padecido con anterioridad o padece...<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_279\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_279 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_279_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_1\" value=\"Obesidad\" \/><label for=\"quform_1_279_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_279_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_279_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_279_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_279_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_279_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_279_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_279_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_279_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_279_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_279_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_279_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_16\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_16\" value=\"Bronquitis cr\u00f3nica\" \/><label for=\"quform_1_279_d2e8c1_16\" class=\"quform-option-label quform-option-label-1_279_16\"><span class=\"quform-option-text\">Bronquitis cr\u00f3nica<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_17\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_17\" value=\"Enfisema\" \/><label for=\"quform_1_279_d2e8c1_17\" class=\"quform-option-label quform-option-label-1_279_17\"><span class=\"quform-option-text\">Enfisema<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_8\" value=\"Otras enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_279_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_279_8\"><span class=\"quform-option-text\">Otras enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_279_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_279_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_279_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_279_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_279_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_279_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_279[]\" id=\"quform_1_279_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_279 quform-field-1_279_14\" value=\"Otros\" \/><label for=\"quform_1_279_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_279_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_280 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_280\"><label class=\"quform-label-text\" for=\"quform_1_280_d2e8c1\">Enumere sus otros antecedentes personales<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_280\"><div class=\"quform-input quform-input-textarea quform-input-1_280 quform-cf\"><textarea id=\"quform_1_280_d2e8c1\" name=\"quform_1_280\" class=\"quform-field quform-field-textarea quform-field-1_280\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_281 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_281\"><label class=\"quform-label-text\" id=\"quform_1_281_d2e8c1_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_281\"><div class=\"quform-input quform-input-radio quform-input-1_281 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_281_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_281\" id=\"quform_1_281_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_281 quform-field-1_281_1\" value=\"No\" \/><label for=\"quform_1_281_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_281_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_281\" id=\"quform_1_281_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_281 quform-field-1_281_2\" value=\"Si\" \/><label for=\"quform_1_281_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_281_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_298 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_298\"><label class=\"quform-label-text\" for=\"quform_1_298_d2e8c1\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_298\"><div class=\"quform-input quform-input-text quform-input-1_298 quform-cf\"><input type=\"text\" id=\"quform_1_298_d2e8c1\" name=\"quform_1_298\" class=\"quform-field quform-field-text quform-field-1_298\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_283 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_283\"><label class=\"quform-label-text\" id=\"quform_1_283_d2e8c1_label\">Antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_283\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_283 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_283_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_1\" value=\"Obesidad\" \/><label for=\"quform_1_283_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_283_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_283_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_283_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_283_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_283_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_283_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_283_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_283_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_283_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_283_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_283_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_283_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_283_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_283_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_283_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_283_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_283_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_283_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_283_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_283[]\" id=\"quform_1_283_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_283 quform-field-1_283_14\" value=\"Otros\" \/><label for=\"quform_1_283_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_283_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_284 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_284\"><label class=\"quform-label-text\" for=\"quform_1_284_d2e8c1\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_284\"><div class=\"quform-input quform-input-textarea quform-input-1_284 quform-cf\"><textarea id=\"quform_1_284_d2e8c1\" name=\"quform_1_284\" class=\"quform-field quform-field-textarea quform-field-1_284\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_285 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00c1BITOS T\u00d3XICOS<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_286 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_286\"><label class=\"quform-label-text\" id=\"quform_1_286_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_286\"><div class=\"quform-input quform-input-radio quform-input-1_286 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_286_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_286\" id=\"quform_1_286_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_286 quform-field-1_286_2\" value=\"Si\" \/><label for=\"quform_1_286_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_286_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_286\" id=\"quform_1_286_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_286 quform-field-1_286_1\" value=\"No\" \/><label for=\"quform_1_286_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_286_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_286\" id=\"quform_1_286_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_286 quform-field-1_286_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_1_286_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_286_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_351 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_351\"><label class=\"quform-label-text\" for=\"quform_1_351_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_351\"><div class=\"quform-input quform-input-text quform-input-1_351 quform-cf\"><input type=\"text\" id=\"quform_1_351_d2e8c1\" name=\"quform_1_351\" class=\"quform-field quform-field-text quform-field-1_351\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_287 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_287\"><label class=\"quform-label-text\" id=\"quform_1_287_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_287\"><div class=\"quform-input quform-input-radio quform-input-1_287 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_287_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_287\" id=\"quform_1_287_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_287 quform-field-1_287_2\" value=\"Si\" \/><label for=\"quform_1_287_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_287_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_287\" id=\"quform_1_287_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_287 quform-field-1_287_1\" value=\"No\" \/><label for=\"quform_1_287_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_287_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_352 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_352\"><label class=\"quform-label-text\" for=\"quform_1_352_d2e8c1\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_352\"><div class=\"quform-input quform-input-text quform-input-1_352 quform-cf\"><input type=\"text\" id=\"quform_1_352_d2e8c1\" name=\"quform_1_352\" class=\"quform-field quform-field-text quform-field-1_352\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_288 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_288\"><label class=\"quform-label-text\" id=\"quform_1_288_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_288\"><div class=\"quform-input quform-input-radio quform-input-1_288 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_288_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_288\" id=\"quform_1_288_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_288 quform-field-1_288_2\" value=\"Si\" \/><label for=\"quform_1_288_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_288_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_288\" id=\"quform_1_288_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_288 quform-field-1_288_1\" value=\"No\" \/><label for=\"quform_1_288_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_288_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_289 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_289\"><label class=\"quform-label-text\" id=\"quform_1_289_d2e8c1_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_289\"><div class=\"quform-input quform-input-radio quform-input-1_289 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_289_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_289\" id=\"quform_1_289_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_289 quform-field-1_289_2\" value=\"Si\" \/><label for=\"quform_1_289_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_289_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_289\" id=\"quform_1_289_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_289 quform-field-1_289_1\" value=\"No\" \/><label for=\"quform_1_289_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_289_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_290 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_290\"><label class=\"quform-label-text\" for=\"quform_1_290_d2e8c1\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_290\"><div class=\"quform-input quform-input-text quform-input-1_290 quform-cf\"><input type=\"text\" id=\"quform_1_290_d2e8c1\" name=\"quform_1_290\" class=\"quform-field quform-field-text quform-field-1_290\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_291 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_291\"><label class=\"quform-label-text\" id=\"quform_1_291_d2e8c1_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_291\"><div class=\"quform-input quform-input-radio quform-input-1_291 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_291_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_291\" id=\"quform_1_291_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_291 quform-field-1_291_2\" value=\"Si\" \/><label for=\"quform_1_291_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_291_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_291\" id=\"quform_1_291_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_291 quform-field-1_291_1\" value=\"No\" \/><label for=\"quform_1_291_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_291_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_292 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_292\"><label class=\"quform-label-text\" for=\"quform_1_292_d2e8c1\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_292\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-1_292 quform-cf\"><textarea id=\"quform_1_292_d2e8c1\" name=\"quform_1_292\" class=\"quform-field quform-field-textarea quform-field-1_292\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_293 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_293\"><label class=\"quform-label-text\" for=\"quform_1_293_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_293\"><div class=\"quform-input quform-input-textarea quform-input-1_293 quform-cf\"><textarea id=\"quform_1_293_d2e8c1\" name=\"quform_1_293\" class=\"quform-field quform-field-textarea quform-field-1_293\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_294 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_294\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_294\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-308 quform-page-1_308 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_309 quform-cf\"><div class=\"quform-spacer\"><h3>Cuestionario de consultas para Experto Health Coach<\/h3><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_339 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_339\"><label class=\"quform-label-text\" for=\"quform_1_339_d2e8c1\">Motivo o diagn\u00f3stico por el cual desea realizar la sesi\u00f3n<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_339\"><div class=\"quform-input quform-input-textarea quform-input-1_339 quform-cf\"><textarea id=\"quform_1_339_d2e8c1\" name=\"quform_1_339\" class=\"quform-field quform-field-textarea quform-field-1_339\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_322 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes personales<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_325 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_325\"><label class=\"quform-label-text\" id=\"quform_1_325_d2e8c1_label\">\u00bfTiene alergia a alg\u00fan medicamento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_325\"><div class=\"quform-input quform-input-radio quform-input-1_325 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_325_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_325\" id=\"quform_1_325_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_325 quform-field-1_325_1\" value=\"No\" \/><label for=\"quform_1_325_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_325_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_325\" id=\"quform_1_325_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_325 quform-field-1_325_2\" value=\"Si\" \/><label for=\"quform_1_325_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_325_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_326 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_326\"><label class=\"quform-label-text\" for=\"quform_1_326_d2e8c1\">Enumere los medicamentos a los que tiene alergia<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_326\"><div class=\"quform-input quform-input-text quform-input-1_326 quform-cf\"><input type=\"text\" id=\"quform_1_326_d2e8c1\" name=\"quform_1_326\" class=\"quform-field quform-field-text quform-field-1_326\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_340 quform-cf\"><div class=\"quform-spacer\"><h3>Antecedentes familiares<\/h3><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_327 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_327\"><label class=\"quform-label-text\" id=\"quform_1_327_d2e8c1_label\">Alguien en su familia ha padecido con anterioridad o padece...<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_327\"><p class=\"quform-description quform-description-above\">Puede seleccionar varias opciones<\/p><div class=\"quform-input quform-input-checkbox quform-input-1_327 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_327_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_1\" value=\"Obesidad\" \/><label for=\"quform_1_327_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_327_1\"><span class=\"quform-option-text\">Obesidad<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_2\" value=\"Colesterol \/ triglic\u00e9ridos altos \" \/><label for=\"quform_1_327_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_327_2\"><span class=\"quform-option-text\">Colesterol \/ triglic\u00e9ridos altos <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_4\" value=\"Diabetes Mellitus\" \/><label for=\"quform_1_327_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_327_4\"><span class=\"quform-option-text\">Diabetes Mellitus<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_5\" value=\"Hipertensi\u00f3n arterial \" \/><label for=\"quform_1_327_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_327_5\"><span class=\"quform-option-text\">Hipertensi\u00f3n arterial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_11\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_11\" value=\"Trastornos del sue\u00f1o \" \/><label for=\"quform_1_327_d2e8c1_11\" class=\"quform-option-label quform-option-label-1_327_11\"><span class=\"quform-option-text\">Trastornos del sue\u00f1o <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_6\" value=\"Asma Bronquial \" \/><label for=\"quform_1_327_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_327_6\"><span class=\"quform-option-text\">Asma Bronquial <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_8\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_8\" value=\"Enfermedades del pulm\u00f3n\" \/><label for=\"quform_1_327_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_327_8\"><span class=\"quform-option-text\">Enfermedades del pulm\u00f3n<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_10\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_10\" value=\"Enfermedades card\u00edacas \" \/><label for=\"quform_1_327_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_327_10\"><span class=\"quform-option-text\">Enfermedades card\u00edacas <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_15\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_15\" value=\"Enfermedades autoimunes  \" \/><label for=\"quform_1_327_d2e8c1_15\" class=\"quform-option-label quform-option-label-1_327_15\"><span class=\"quform-option-text\">Enfermedades autoimunes  <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_12\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_12\" value=\"C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago\" \/><label for=\"quform_1_327_d2e8c1_12\" class=\"quform-option-label quform-option-label-1_327_12\"><span class=\"quform-option-text\">C\u00e1ncer:  mama, pulm\u00f3n, es\u00f3fago, est\u00f3mago<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_327[]\" id=\"quform_1_327_d2e8c1_14\" class=\"quform-field quform-field-checkbox quform-field-1_327 quform-field-1_327_14\" value=\"Otros\" \/><label for=\"quform_1_327_d2e8c1_14\" class=\"quform-option-label quform-option-label-1_327_14\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_328 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_328\"><label class=\"quform-label-text\" for=\"quform_1_328_d2e8c1\">Enumere sus otros antecedentes familiares<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_328\"><div class=\"quform-input quform-input-textarea quform-input-1_328 quform-cf\"><textarea id=\"quform_1_328_d2e8c1\" name=\"quform_1_328\" class=\"quform-field quform-field-textarea quform-field-1_328\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_329 quform-cf\"><div class=\"quform-spacer\"><h3>H\u00e1bitos t\u00f3xicos<\/h3><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_330 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_330\"><label class=\"quform-label-text\" id=\"quform_1_330_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_330\"><div class=\"quform-input quform-input-radio quform-input-1_330 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_330_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_330\" id=\"quform_1_330_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_330 quform-field-1_330_2\" value=\"Si\" \/><label for=\"quform_1_330_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_330_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_330\" id=\"quform_1_330_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_330 quform-field-1_330_1\" value=\"No\" \/><label for=\"quform_1_330_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_330_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_330\" id=\"quform_1_330_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_330 quform-field-1_330_4\" value=\"Ex fumador\/a\" \/><label for=\"quform_1_330_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_330_4\"><span class=\"quform-option-text\">Ex fumador\/a<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_353 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_353\"><label class=\"quform-label-text\" for=\"quform_1_353_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_353\"><div class=\"quform-input quform-input-text quform-input-1_353 quform-cf\"><input type=\"text\" id=\"quform_1_353_d2e8c1\" name=\"quform_1_353\" class=\"quform-field quform-field-text quform-field-1_353\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_331 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_331\"><label class=\"quform-label-text\" id=\"quform_1_331_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_331\"><div class=\"quform-input quform-input-radio quform-input-1_331 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_331_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_331\" id=\"quform_1_331_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_331 quform-field-1_331_2\" value=\"Si\" \/><label for=\"quform_1_331_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_331_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_331\" id=\"quform_1_331_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_331 quform-field-1_331_1\" value=\"No\" \/><label for=\"quform_1_331_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_331_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_354 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_354\"><label class=\"quform-label-text\" for=\"quform_1_354_d2e8c1\">Cu\u00e1nto alcohol consume al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_354\"><div class=\"quform-input quform-input-text quform-input-1_354 quform-cf\"><input type=\"text\" id=\"quform_1_354_d2e8c1\" name=\"quform_1_354\" class=\"quform-field quform-field-text quform-field-1_354\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_332 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_332\"><label class=\"quform-label-text\" id=\"quform_1_332_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_332\"><div class=\"quform-input quform-input-radio quform-input-1_332 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_332_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_332\" id=\"quform_1_332_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_332 quform-field-1_332_2\" value=\"Si\" \/><label for=\"quform_1_332_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_332_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_332\" id=\"quform_1_332_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_332 quform-field-1_332_1\" value=\"No\" \/><label for=\"quform_1_332_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_332_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_333 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_333\"><label class=\"quform-label-text\" id=\"quform_1_333_d2e8c1_label\">Cirug\u00edas previas<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_333\"><div class=\"quform-input quform-input-radio quform-input-1_333 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_333_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_333\" id=\"quform_1_333_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_333 quform-field-1_333_2\" value=\"Si\" \/><label for=\"quform_1_333_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_333_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_333\" id=\"quform_1_333_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_333 quform-field-1_333_1\" value=\"No\" \/><label for=\"quform_1_333_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_333_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_334 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_334\"><label class=\"quform-label-text\" for=\"quform_1_334_d2e8c1\">Enumere sus cirug\u00edas previas<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_334\"><div class=\"quform-input quform-input-text quform-input-1_334 quform-cf\"><input type=\"text\" id=\"quform_1_334_d2e8c1\" name=\"quform_1_334\" class=\"quform-field quform-field-text quform-field-1_334\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_335 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_335\"><label class=\"quform-label-text\" id=\"quform_1_335_d2e8c1_label\">\u00bfEst\u00e1 actualmente bajo alg\u00fan tratamiento?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_335\"><div class=\"quform-input quform-input-radio quform-input-1_335 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_335_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_335\" id=\"quform_1_335_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_335 quform-field-1_335_2\" value=\"Si\" \/><label for=\"quform_1_335_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_335_2\"><span class=\"quform-option-text\">Si<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_335\" id=\"quform_1_335_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_335 quform-field-1_335_1\" value=\"No\" \/><label for=\"quform_1_335_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_335_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_336 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_336\"><label class=\"quform-label-text\" for=\"quform_1_336_d2e8c1\">Detalle su tratamiento actual<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_336\"><p class=\"quform-description quform-description-above\">Nombre del o los medicamento\/s, miligramos y dosis<\/p><div class=\"quform-input quform-input-textarea quform-input-1_336 quform-cf\"><textarea id=\"quform_1_336_d2e8c1\" name=\"quform_1_336\" class=\"quform-field quform-field-textarea quform-field-1_336\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_337 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_337\"><label class=\"quform-label-text\" for=\"quform_1_337_d2e8c1\"> Por favor, d\u00e9jenos un breve comentario sobre el motivo de su consulta en nuestro centro VIDAIR:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_337\"><div class=\"quform-input quform-input-textarea quform-input-1_337 quform-cf\"><textarea id=\"quform_1_337_d2e8c1\" name=\"quform_1_337\" class=\"quform-field quform-field-textarea quform-field-1_337\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_338 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_338\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_338\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-99 quform-page-1_99 quform-cf quform-group-style-plain\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_100 quform-cf\"><div class=\"quform-spacer\"><h3>Historia cl\u00ednica Trastornos del Sue\u00f1o<\/h3><br \/>\nEn la consulta de Trastorno del Sue\u00f1o es fundamental conocer algunos detalles de su d\u00eda a d\u00eda.<br \/>\n<br \/>\nSu dolencia es nuestra prioridad. En VIDAIR queremos dedicar todo nuestro tiempo a evaluar sus necesidades y buscar una soluci\u00f3n, por ello necesitamos que nos facilite ciertos datos antes de la consulta.<\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_120 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Antecedentes personales<\/strong><\/h4><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_104 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_104\"><label class=\"quform-label-text\" for=\"quform_1_104_d2e8c1\">\u00bfCual es su puesto de trabajo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_104\"><div class=\"quform-input quform-input-text quform-input-1_104 quform-cf\"><input type=\"text\" id=\"quform_1_104_d2e8c1\" name=\"quform_1_104\" class=\"quform-field quform-field-text quform-field-1_104\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_101 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_101\"><label class=\"quform-label-text\" id=\"quform_1_101_d2e8c1_label\">\u00bfQu\u00e9 turnos desarrolla en su puesto de trabajo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_101\"><div class=\"quform-input quform-input-checkbox quform-input-1_101 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_101_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_101[]\" id=\"quform_1_101_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_101 quform-field-1_101_1\" value=\"Ma\u00f1ana\" \/><label for=\"quform_1_101_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_101_1\"><span class=\"quform-option-text\">Ma\u00f1ana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_101[]\" id=\"quform_1_101_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_101 quform-field-1_101_2\" value=\"Tarde\" \/><label for=\"quform_1_101_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_101_2\"><span class=\"quform-option-text\">Tarde<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_101[]\" id=\"quform_1_101_d2e8c1_3\" class=\"quform-field quform-field-checkbox quform-field-1_101 quform-field-1_101_3\" value=\"Ma\u00f1ana y tarde\" \/><label for=\"quform_1_101_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_101_3\"><span class=\"quform-option-text\">Ma\u00f1ana y tarde<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_101[]\" id=\"quform_1_101_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_101 quform-field-1_101_4\" value=\"Noche\" \/><label for=\"quform_1_101_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_101_4\"><span class=\"quform-option-text\">Noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_101[]\" id=\"quform_1_101_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_101 quform-field-1_101_5\" value=\"Turnos partidos\" \/><label for=\"quform_1_101_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_101_5\"><span class=\"quform-option-text\">Turnos partidos<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_119 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_119\"><label class=\"quform-label-text\" id=\"quform_1_119_d2e8c1_label\">\u00bfTrabaja como conductor\/a profesional?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_119\"><div class=\"quform-input quform-input-radio quform-input-1_119 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_119_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_119\" id=\"quform_1_119_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_119 quform-field-1_119_1\" value=\"SI\" \/><label for=\"quform_1_119_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_119_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_119\" id=\"quform_1_119_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_119 quform-field-1_119_2\" value=\"NO\" \/><label for=\"quform_1_119_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_119_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_106 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_106\"><label class=\"quform-label-text\" for=\"quform_1_106_d2e8c1\">Tipo de conductor<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_106\"><div class=\"quform-input quform-input-text quform-input-1_106 quform-cf\"><input type=\"text\" id=\"quform_1_106_d2e8c1\" name=\"quform_1_106\" class=\"quform-field quform-field-text quform-field-1_106\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_117 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_117\"><label class=\"quform-label-text\" id=\"quform_1_117_d2e8c1_label\">\u00bfEs fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_117\"><div class=\"quform-input quform-input-radio quform-input-1_117 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_117_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_117\" id=\"quform_1_117_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_117 quform-field-1_117_1\" value=\"SI\" \/><label for=\"quform_1_117_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_117_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_117\" id=\"quform_1_117_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_117 quform-field-1_117_2\" value=\"NO\" \/><label for=\"quform_1_117_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_117_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_117\" id=\"quform_1_117_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_117 quform-field-1_117_4\" value=\"EX FUMADOR\/A\" \/><label for=\"quform_1_117_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_117_4\"><span class=\"quform-option-text\">EX FUMADOR\/A<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_108 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_108\"><label class=\"quform-label-text\" for=\"quform_1_108_d2e8c1\">N\u00ba Cigarrillos que fuma al d\u00eda<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_108\"><div class=\"quform-input quform-input-text quform-input-1_108 quform-cf\"><input type=\"text\" id=\"quform_1_108_d2e8c1\" name=\"quform_1_108\" class=\"quform-field quform-field-text quform-field-1_108\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_109 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_109\"><label class=\"quform-label-text\" for=\"quform_1_109_d2e8c1\">\u00bfDesde qu\u00e9 edad y hasta qu\u00e9 edad fue fumador\/a?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_109\"><div class=\"quform-input quform-input-text quform-input-1_109 quform-cf\"><input type=\"text\" id=\"quform_1_109_d2e8c1\" name=\"quform_1_109\" class=\"quform-field quform-field-text quform-field-1_109\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_110 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_110\"><label class=\"quform-label-text\" for=\"quform_1_110_d2e8c1\">\u00bfCu\u00e1nto fumaba aproximadamente?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_110\"><div class=\"quform-input quform-input-text quform-input-1_110 quform-cf\"><input type=\"text\" id=\"quform_1_110_d2e8c1\" name=\"quform_1_110\" class=\"quform-field quform-field-text quform-field-1_110\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_118 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_118\"><label class=\"quform-label-text\" id=\"quform_1_118_d2e8c1_label\">\u00bfToma alcohol?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_118\"><div class=\"quform-input quform-input-radio quform-input-1_118 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_118_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_118\" id=\"quform_1_118_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_118 quform-field-1_118_1\" value=\"SI\" \/><label for=\"quform_1_118_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_118_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_118\" id=\"quform_1_118_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_118 quform-field-1_118_2\" value=\"NO\" \/><label for=\"quform_1_118_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_118_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_112 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_112\"><label class=\"quform-label-text\" for=\"quform_1_112_d2e8c1\">\u00bfCu\u00e1nto alcohol consume al d\u00eda?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_112\"><div class=\"quform-input quform-input-text quform-input-1_112 quform-cf\"><input type=\"text\" id=\"quform_1_112_d2e8c1\" name=\"quform_1_112\" class=\"quform-field quform-field-text quform-field-1_112\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_116 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_116\"><label class=\"quform-label-text\" id=\"quform_1_116_d2e8c1_label\">\u00bfToma medicamentos para dormir?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_116\"><div class=\"quform-input quform-input-radio quform-input-1_116 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_116_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_116\" id=\"quform_1_116_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_116 quform-field-1_116_1\" value=\"SI\" \/><label for=\"quform_1_116_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_116_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_116\" id=\"quform_1_116_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_116 quform-field-1_116_2\" value=\"NO\" \/><label for=\"quform_1_116_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_116_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_114 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_114\"><label class=\"quform-label-text\" for=\"quform_1_114_d2e8c1\">Nombre del medicamento, miligramos y dosis<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_114\"><div class=\"quform-input quform-input-text quform-input-1_114 quform-cf\"><input type=\"text\" id=\"quform_1_114_d2e8c1\" name=\"quform_1_114\" class=\"quform-field quform-field-text quform-field-1_114\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_121 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Signos y s\u00edntomas de Trastornos Respiratorios del Sue\u00f1o<\/strong><\/h4><br \/>\nPor favor, lea detenidamente cada una de las siguientes preguntas, y seleccione con la respuesta que m\u00e1s se asemeje a lo que le est\u00e1 ocurriendo actualmente.<\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_123 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_124\"><div class=\"quform-element quform-element-text quform-element-1_132 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_132\"><label class=\"quform-label-text\" for=\"quform_1_132_d2e8c1\">\u00bfA qu\u00e9 hora se acuesta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_132\"><div class=\"quform-input quform-input-text quform-input-1_132 quform-cf\"><input type=\"text\" id=\"quform_1_132_d2e8c1\" name=\"quform_1_132\" class=\"quform-field quform-field-text quform-field-1_132\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_125\"><div class=\"quform-element quform-element-text quform-element-1_127 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_127\"><label class=\"quform-label-text\" for=\"quform_1_127_d2e8c1\">\u00bfA qu\u00e9 hora se despierta-levanta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_127\"><div class=\"quform-input quform-input-text quform-input-1_127 quform-cf\"><input type=\"text\" id=\"quform_1_127_d2e8c1\" name=\"quform_1_127\" class=\"quform-field quform-field-text quform-field-1_127\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_130 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_130\"><label class=\"quform-label-text\" id=\"quform_1_130_d2e8c1_label\">\u00bfCu\u00e1nto tiempo dura para dormirse?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_130\"><div class=\"quform-input quform-input-radio quform-input-1_130 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_130_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_130\" id=\"quform_1_130_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_130 quform-field-1_130_1\" value=\"Menos de 30 minutos\" \/><label for=\"quform_1_130_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_130_1\"><span class=\"quform-option-text\">Menos de 30 minutos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_130\" id=\"quform_1_130_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_130 quform-field-1_130_2\" value=\"30 minutos - 1 hora\" \/><label for=\"quform_1_130_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_130_2\"><span class=\"quform-option-text\">30 minutos - 1 hora<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_130\" id=\"quform_1_130_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_130 quform-field-1_130_3\" value=\"1 - 2 horas\" \/><label for=\"quform_1_130_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_130_3\"><span class=\"quform-option-text\">1 - 2 horas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_130\" id=\"quform_1_130_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_130 quform-field-1_130_4\" value=\"M\u00e1s de 2 horas\" \/><label for=\"quform_1_130_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_130_4\"><span class=\"quform-option-text\">M\u00e1s de 2 horas<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_131 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_131\"><label class=\"quform-label-text\" id=\"quform_1_131_d2e8c1_label\">\u00bfDuerme la siesta?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_131\"><div class=\"quform-input quform-input-radio quform-input-1_131 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_131_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_131\" id=\"quform_1_131_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_131 quform-field-1_131_1\" value=\"SI\" \/><label for=\"quform_1_131_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_131_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_131\" id=\"quform_1_131_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_131 quform-field-1_131_2\" value=\"NO\" \/><label for=\"quform_1_131_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_131_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_126 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_126\"><label class=\"quform-label-text\" for=\"quform_1_126_d2e8c1\">\u00bfCu\u00e1nto suelen durar sus siestas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_126\"><div class=\"quform-input quform-input-text quform-input-1_126 quform-cf\"><input type=\"text\" id=\"quform_1_126_d2e8c1\" name=\"quform_1_126\" class=\"quform-field quform-field-text quform-field-1_126\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_133 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_133\"><label class=\"quform-label-text\" id=\"quform_1_133_d2e8c1_label\">\u00bfPresenta ronquidos?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_133\"><div class=\"quform-input quform-input-radio quform-input-1_133 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_133_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_133\" id=\"quform_1_133_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_133 quform-field-1_133_1\" value=\"SI\" \/><label for=\"quform_1_133_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_133_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_133\" id=\"quform_1_133_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_133 quform-field-1_133_2\" value=\"NO\" \/><label for=\"quform_1_133_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_133_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_134 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_134\"><label class=\"quform-label-text\" id=\"quform_1_134_d2e8c1_label\">\u00bfDesde cu\u00e1ndo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_134\"><div class=\"quform-input quform-input-radio quform-input-1_134 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_134_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_134\" id=\"quform_1_134_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_134 quform-field-1_134_1\" value=\"Menos de 1 a\u00f1o\" \/><label for=\"quform_1_134_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_134_1\"><span class=\"quform-option-text\">Menos de 1 a\u00f1o<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_134\" id=\"quform_1_134_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_134 quform-field-1_134_2\" value=\"De 1 a 3 a\u00f1os\" \/><label for=\"quform_1_134_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_134_2\"><span class=\"quform-option-text\">De 1 a 3 a\u00f1os<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_134\" id=\"quform_1_134_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_134 quform-field-1_134_3\" value=\"De 3 a 5 a\u00f1os\" \/><label for=\"quform_1_134_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_134_3\"><span class=\"quform-option-text\">De 3 a 5 a\u00f1os<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_134\" id=\"quform_1_134_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_134 quform-field-1_134_4\" value=\"M\u00e1s de 5 a\u00f1os\" \/><label for=\"quform_1_134_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_134_4\"><span class=\"quform-option-text\">M\u00e1s de 5 a\u00f1os<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_145 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_137 quform-cf\"><div class=\"quform-spacer\"><h4>Con relaci\u00f3n a su ronquido<\/h4><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_146 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_147\"><div class=\"quform-element quform-element-radio quform-element-1_138 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_138\"><label class=\"quform-label-text\" id=\"quform_1_138_d2e8c1_label\">\u00bfSu ronquido se escucha fuera de la habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_138\"><div class=\"quform-input quform-input-radio quform-input-1_138 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_138_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_138\" id=\"quform_1_138_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_138 quform-field-1_138_1\" value=\"SI\" \/><label for=\"quform_1_138_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_138_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_138\" id=\"quform_1_138_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_138 quform-field-1_138_2\" value=\"NO\" \/><label for=\"quform_1_138_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_138_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_138\" id=\"quform_1_138_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_138 quform-field-1_138_5\" value=\"A VECES\" \/><label for=\"quform_1_138_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_138_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_138\" id=\"quform_1_138_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_138 quform-field-1_138_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_138_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_138_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_148\"><div class=\"quform-element quform-element-radio quform-element-1_140 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_140\"><label class=\"quform-label-text\" id=\"quform_1_140_d2e8c1_label\">\u00bfSu ronquido despierta a su compa\u00f1ero de cama - habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_140\"><div class=\"quform-input quform-input-radio quform-input-1_140 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_140_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_140\" id=\"quform_1_140_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_140 quform-field-1_140_1\" value=\"SI\" \/><label for=\"quform_1_140_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_140_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_140\" id=\"quform_1_140_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_140 quform-field-1_140_2\" value=\"NO\" \/><label for=\"quform_1_140_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_140_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_140\" id=\"quform_1_140_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_140 quform-field-1_140_5\" value=\"A VECES\" \/><label for=\"quform_1_140_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_140_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_140\" id=\"quform_1_140_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_140 quform-field-1_140_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_140_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_140_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_149 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_150\"><div class=\"quform-element quform-element-radio quform-element-1_141 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_141\"><label class=\"quform-label-text\" id=\"quform_1_141_d2e8c1_label\">\u00bfSu ronquido provoca insomnio a su compa\u00f1ero\/a de cama - habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_141\"><div class=\"quform-input quform-input-radio quform-input-1_141 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_141_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_141\" id=\"quform_1_141_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_141 quform-field-1_141_1\" value=\"SI\" \/><label for=\"quform_1_141_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_141_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_141\" id=\"quform_1_141_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_141 quform-field-1_141_2\" value=\"NO\" \/><label for=\"quform_1_141_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_141_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_141\" id=\"quform_1_141_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_141 quform-field-1_141_5\" value=\"A VECES\" \/><label for=\"quform_1_141_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_141_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_141\" id=\"quform_1_141_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_141 quform-field-1_141_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_141_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_141_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_152\"><div class=\"quform-element quform-element-radio quform-element-1_142 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_142\"><label class=\"quform-label-text\" id=\"quform_1_142_d2e8c1_label\">\u00bfSu ronquido obliga a su compa\u00f1ero de cama \/ habitaci\u00f3n a dormir en otra habitaci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_142\"><div class=\"quform-input quform-input-radio quform-input-1_142 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_142_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_142\" id=\"quform_1_142_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_142 quform-field-1_142_1\" value=\"SI\" \/><label for=\"quform_1_142_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_142_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_142\" id=\"quform_1_142_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_142 quform-field-1_142_2\" value=\"NO\" \/><label for=\"quform_1_142_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_142_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_142\" id=\"quform_1_142_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_142 quform-field-1_142_5\" value=\"A VECES\" \/><label for=\"quform_1_142_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_142_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_142\" id=\"quform_1_142_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_142 quform-field-1_142_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_142_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_142_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_155 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_156\"><div class=\"quform-element quform-element-radio quform-element-1_143 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_143\"><label class=\"quform-label-text\" id=\"quform_1_143_d2e8c1_label\">\u00bfLe han dicho que hace paradas respiratorias mientras duerme (apneas)?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_143\"><div class=\"quform-input quform-input-radio quform-input-1_143 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_143_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_143\" id=\"quform_1_143_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_143 quform-field-1_143_1\" value=\"SI\" \/><label for=\"quform_1_143_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_143_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_143\" id=\"quform_1_143_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_143 quform-field-1_143_2\" value=\"NO\" \/><label for=\"quform_1_143_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_143_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_143\" id=\"quform_1_143_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_143 quform-field-1_143_5\" value=\"A VECES\" \/><label for=\"quform_1_143_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_143_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_143\" id=\"quform_1_143_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_143 quform-field-1_143_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_143_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_143_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_158\"><div class=\"quform-element quform-element-radio quform-element-1_144 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_144\"><label class=\"quform-label-text\" id=\"quform_1_144_d2e8c1_label\">\u00bfSe despierta con falta de aire o sensaci\u00f3n de ahogo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_144\"><div class=\"quform-input quform-input-radio quform-input-1_144 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_144_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_144\" id=\"quform_1_144_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_144 quform-field-1_144_1\" value=\"SI\" \/><label for=\"quform_1_144_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_144_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_144\" id=\"quform_1_144_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_144 quform-field-1_144_2\" value=\"NO\" \/><label for=\"quform_1_144_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_144_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_144\" id=\"quform_1_144_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_144 quform-field-1_144_5\" value=\"A VECES\" \/><label for=\"quform_1_144_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_144_5\"><span class=\"quform-option-text\">A VECES<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_144\" id=\"quform_1_144_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_144 quform-field-1_144_6\" value=\"CASI SIEMPRE\" \/><label for=\"quform_1_144_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_144_6\"><span class=\"quform-option-text\">CASI SIEMPRE<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_160 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_160\"><label class=\"quform-label-text\" id=\"quform_1_160_d2e8c1_label\">\u00bfSe levanta a orinar durante la noche?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_160\"><div class=\"quform-input quform-input-radio quform-input-1_160 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_160_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_160\" id=\"quform_1_160_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_160 quform-field-1_160_1\" value=\"SI\" \/><label for=\"quform_1_160_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_160_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_160\" id=\"quform_1_160_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_160 quform-field-1_160_2\" value=\"NO\" \/><label for=\"quform_1_160_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_160_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_161 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_161\"><label class=\"quform-label-text\" id=\"quform_1_161_d2e8c1_label\">\u00bfCu\u00e1ntas veces?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_161\"><div class=\"quform-input quform-input-radio quform-input-1_161 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_161_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_161\" id=\"quform_1_161_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_161 quform-field-1_161_1\" value=\"1 \/ 2 por noche\" \/><label for=\"quform_1_161_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_161_1\"><span class=\"quform-option-text\">1 \/ 2 por noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_161\" id=\"quform_1_161_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_161 quform-field-1_161_2\" value=\"M\u00e1s de 2 veces por noche\" \/><label for=\"quform_1_161_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_161_2\"><span class=\"quform-option-text\">M\u00e1s de 2 veces por noche<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_162 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_162\"><label class=\"quform-label-text\" id=\"quform_1_162_d2e8c1_label\">\u00bfSe despierta durante la noche, despertares de larga duraci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_162\"><div class=\"quform-input quform-input-radio quform-input-1_162 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_162_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_162\" id=\"quform_1_162_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_162 quform-field-1_162_1\" value=\"SI\" \/><label for=\"quform_1_162_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_162_1\"><span class=\"quform-option-text\">SI<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_162\" id=\"quform_1_162_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_162 quform-field-1_162_2\" value=\"NO\" \/><label for=\"quform_1_162_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_162_2\"><span class=\"quform-option-text\">NO<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_164 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_164\"><label class=\"quform-label-text\" id=\"quform_1_164_d2e8c1_label\">\u00bfCu\u00e1l suele ser el motivo de su desvelo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_164\"><div class=\"quform-input quform-input-checkbox quform-input-1_164 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_164_d2e8c1_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_1\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_1\" value=\"Orinar\" \/><label for=\"quform_1_164_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_164_1\"><span class=\"quform-option-text\">Orinar<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_2\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_2\" value=\"Dolor\" \/><label for=\"quform_1_164_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_164_2\"><span class=\"quform-option-text\">Dolor<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_3\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_3\" value=\"No sabe\" \/><label for=\"quform_1_164_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_164_3\"><span class=\"quform-option-text\">No sabe<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_4\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_4\" value=\"Pesadillas\" \/><label for=\"quform_1_164_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_164_4\"><span class=\"quform-option-text\">Pesadillas<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_5\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_5\" value=\"Ruidos\" \/><label for=\"quform_1_164_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_164_5\"><span class=\"quform-option-text\">Ruidos<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_164[]\" id=\"quform_1_164_d2e8c1_6\" class=\"quform-field quform-field-checkbox quform-field-1_164 quform-field-1_164_6\" value=\"Otros\" \/><label for=\"quform_1_164_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_164_6\"><span class=\"quform-option-text\">Otros<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_165 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_165\"><label class=\"quform-label-text\" for=\"quform_1_165_d2e8c1\">Cu\u00e9ntenos el motivo de su desvelo<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_165\"><div class=\"quform-input quform-input-text quform-input-1_165 quform-cf\"><input type=\"text\" id=\"quform_1_165_d2e8c1\" name=\"quform_1_165\" class=\"quform-field quform-field-text quform-field-1_165\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_166 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_166\"><label class=\"quform-label-text\" id=\"quform_1_166_d2e8c1_label\">\u00bfDespierta varias veces durante la noche sin motivo?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_166\"><div class=\"quform-input quform-input-radio quform-input-1_166 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_166_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_166\" id=\"quform_1_166_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_166 quform-field-1_166_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_1_166_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_166_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_166\" id=\"quform_1_166_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_166 quform-field-1_166_2\" value=\" 2 veces o m\u00e1s por noche\" \/><label for=\"quform_1_166_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_166_2\"><span class=\"quform-option-text\"> 2 veces o m\u00e1s por noche<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_166\" id=\"quform_1_166_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_166 quform-field-1_166_5\" value=\"Diario\" \/><label for=\"quform_1_166_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_166_5\"><span class=\"quform-option-text\">Diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_167 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_167\"><label class=\"quform-label-text\" id=\"quform_1_167_d2e8c1_label\">\u00bfCu\u00e1ndo amanece, tiene la sensaci\u00f3n de que no ha dormido \/ descansado correctamente? (Sue\u00f1o no reparador)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_167\"><div class=\"quform-input quform-input-radio quform-input-1_167 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_167_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_167\" id=\"quform_1_167_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_167 quform-field-1_167_1\" value=\"Nunca\" \/><label for=\"quform_1_167_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_167_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_167\" id=\"quform_1_167_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_167 quform-field-1_167_2\" value=\"Casi nunca\" \/><label for=\"quform_1_167_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_167_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_167\" id=\"quform_1_167_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_167 quform-field-1_167_5\" value=\"A veces\" \/><label for=\"quform_1_167_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_167_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_167\" id=\"quform_1_167_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_167 quform-field-1_167_6\" value=\"Siempre\" \/><label for=\"quform_1_167_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_167_6\"><span class=\"quform-option-text\">Siempre<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_168 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_168\"><label class=\"quform-label-text\" id=\"quform_1_168_d2e8c1_label\">\u00bfLe cuesta despertarse \/ levantarse por la ma\u00f1ana?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_168\"><div class=\"quform-input quform-input-radio quform-input-1_168 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_168_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_168\" id=\"quform_1_168_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_168 quform-field-1_168_1\" value=\"Nunca\" \/><label for=\"quform_1_168_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_168_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_168\" id=\"quform_1_168_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_168 quform-field-1_168_2\" value=\"Casi nunca\" \/><label for=\"quform_1_168_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_168_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_168\" id=\"quform_1_168_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_168 quform-field-1_168_5\" value=\"A veces\" \/><label for=\"quform_1_168_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_168_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_168\" id=\"quform_1_168_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_168 quform-field-1_168_6\" value=\"Siempre\" \/><label for=\"quform_1_168_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_168_6\"><span class=\"quform-option-text\">Siempre<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_169 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_169\"><label class=\"quform-label-text\" id=\"quform_1_169_d2e8c1_label\">\u00bfPresenta cansancio o falta de energ\u00eda durante el d\u00eda?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_169\"><div class=\"quform-input quform-input-radio quform-input-1_169 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_169_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_169\" id=\"quform_1_169_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_169 quform-field-1_169_1\" value=\"Nunca\" \/><label for=\"quform_1_169_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_169_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_169\" id=\"quform_1_169_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_169 quform-field-1_169_2\" value=\"Casi nunca\" \/><label for=\"quform_1_169_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_169_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_169\" id=\"quform_1_169_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_169 quform-field-1_169_5\" value=\"A veces\" \/><label for=\"quform_1_169_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_169_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_169\" id=\"quform_1_169_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_169 quform-field-1_169_6\" value=\"Muchas veces\" \/><label for=\"quform_1_169_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_169_6\"><span class=\"quform-option-text\">Muchas veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_169\" id=\"quform_1_169_d2e8c1_7\" class=\"quform-field quform-field-radio quform-field-1_169 quform-field-1_169_7\" value=\"A diario\" \/><label for=\"quform_1_169_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_169_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_170 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_170\"><label class=\"quform-label-text\" id=\"quform_1_170_d2e8c1_label\">\u00bfPresenta dificultad para realizar sus actividades de la vida diaria por cansancio o falta de concentraci\u00f3n?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_170\"><div class=\"quform-input quform-input-radio quform-input-1_170 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_170_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_170\" id=\"quform_1_170_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_170 quform-field-1_170_1\" value=\"Nunca\" \/><label for=\"quform_1_170_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_170_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_170\" id=\"quform_1_170_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_170 quform-field-1_170_2\" value=\"Casi nunca\" \/><label for=\"quform_1_170_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_170_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_170\" id=\"quform_1_170_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_170 quform-field-1_170_5\" value=\"A veces\" \/><label for=\"quform_1_170_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_170_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_170\" id=\"quform_1_170_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_170 quform-field-1_170_6\" value=\"Muchas veces a la semana\" \/><label for=\"quform_1_170_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_170_6\"><span class=\"quform-option-text\">Muchas veces a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_170\" id=\"quform_1_170_d2e8c1_7\" class=\"quform-field quform-field-radio quform-field-1_170 quform-field-1_170_7\" value=\"A diario\" \/><label for=\"quform_1_170_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_170_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_171 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_171\"><label class=\"quform-label-text\" id=\"quform_1_171_d2e8c1_label\">\u00bfCu\u00e1ndo sue\u00f1a, recuerda el sue\u00f1o tras despertar?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_171\"><div class=\"quform-input quform-input-radio quform-input-1_171 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_171_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_171\" id=\"quform_1_171_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_171 quform-field-1_171_1\" value=\"Nunca\" \/><label for=\"quform_1_171_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_171_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_171\" id=\"quform_1_171_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_171 quform-field-1_171_2\" value=\"Casi nunca\" \/><label for=\"quform_1_171_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_171_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_171\" id=\"quform_1_171_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_171 quform-field-1_171_5\" value=\"A veces\" \/><label for=\"quform_1_171_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_171_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_171\" id=\"quform_1_171_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_171 quform-field-1_171_6\" value=\"Muchas veces\" \/><label for=\"quform_1_171_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_171_6\"><span class=\"quform-option-text\">Muchas veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_171\" id=\"quform_1_171_d2e8c1_7\" class=\"quform-field quform-field-radio quform-field-1_171 quform-field-1_171_7\" value=\"A diario\" \/><label for=\"quform_1_171_d2e8c1_7\" class=\"quform-option-label quform-option-label-1_171_7\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_172 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_172\"><label class=\"quform-label-text\" id=\"quform_1_172_d2e8c1_label\">\u00bfPresenta dificultad para respirar, fatiga o falta de aire?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_172\"><div class=\"quform-input quform-input-radio quform-input-1_172 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_172_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_172\" id=\"quform_1_172_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_172 quform-field-1_172_1\" value=\"Nunca\" \/><label for=\"quform_1_172_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_172_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_172\" id=\"quform_1_172_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_172 quform-field-1_172_2\" value=\"S\u00f3lo al caminar de prisa o subir una cuesta\" \/><label for=\"quform_1_172_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_172_2\"><span class=\"quform-option-text\">S\u00f3lo al caminar de prisa o subir una cuesta<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_172\" id=\"quform_1_172_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_172 quform-field-1_172_5\" value=\"Debo parar al caminar en llano\" \/><label for=\"quform_1_172_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_172_5\"><span class=\"quform-option-text\">Debo parar al caminar en llano<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_172\" id=\"quform_1_172_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_172 quform-field-1_172_6\" value=\"Tengo limitaci\u00f3n al vestirme en casa\" \/><label for=\"quform_1_172_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_172_6\"><span class=\"quform-option-text\">Tengo limitaci\u00f3n al vestirme en casa<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_173 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_173\"><label class=\"quform-label-text\" id=\"quform_1_173_d2e8c1_label\">\u00bfAl despertar, tiene dolor de cabeza?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_173\"><div class=\"quform-input quform-input-radio quform-input-1_173 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_173_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_173\" id=\"quform_1_173_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_173 quform-field-1_173_1\" value=\"Nunca\" \/><label for=\"quform_1_173_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_173_1\"><span class=\"quform-option-text\">Nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_173\" id=\"quform_1_173_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_173 quform-field-1_173_2\" value=\"Casi nunca\" \/><label for=\"quform_1_173_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_173_2\"><span class=\"quform-option-text\">Casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_173\" id=\"quform_1_173_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_173 quform-field-1_173_5\" value=\"A veces\" \/><label for=\"quform_1_173_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_173_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_173\" id=\"quform_1_173_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_173 quform-field-1_173_6\" value=\"Muchas veces a la semana\" \/><label for=\"quform_1_173_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_173_6\"><span class=\"quform-option-text\">Muchas veces a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_173\" id=\"quform_1_173_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_173 quform-field-1_173_8\" value=\"A diario\" \/><label for=\"quform_1_173_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_173_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_174 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_174\"><label class=\"quform-label-text\" id=\"quform_1_174_d2e8c1_label\">\u00bfNota sue\u00f1o durante el d\u00eda en horas no habituales (Somnolencia Excesiva Diurna)?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_174\"><div class=\"quform-input quform-input-radio quform-input-1_174 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_174_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_174\" id=\"quform_1_174_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_174 quform-field-1_174_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_1_174_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_174_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_174\" id=\"quform_1_174_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_174 quform-field-1_174_5\" value=\"A veces\" \/><label for=\"quform_1_174_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_174_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_174\" id=\"quform_1_174_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_174 quform-field-1_174_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_1_174_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_174_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_174\" id=\"quform_1_174_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_174 quform-field-1_174_8\" value=\"A diario\" \/><label for=\"quform_1_174_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_174_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_175 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_175\"><label class=\"quform-label-text\" id=\"quform_1_175_d2e8c1_label\">\u00bfDificulta la somnolencia realizar sus actividades de la vida diaria?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_175\"><div class=\"quform-input quform-input-radio quform-input-1_175 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_175_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_175\" id=\"quform_1_175_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_175 quform-field-1_175_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_1_175_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_175_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_175\" id=\"quform_1_175_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_175 quform-field-1_175_5\" value=\"A veces\" \/><label for=\"quform_1_175_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_175_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_175\" id=\"quform_1_175_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_175 quform-field-1_175_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_1_175_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_175_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_175\" id=\"quform_1_175_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_175 quform-field-1_175_8\" value=\"A diario\" \/><label for=\"quform_1_175_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_175_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_176 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_176\"><label class=\"quform-label-text\" id=\"quform_1_176_d2e8c1_label\">\u00bfCu\u00e1ndo se acuesta, presenta hormigueo en las piernas o necesidad de moverlas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_176\"><div class=\"quform-input quform-input-radio quform-input-1_176 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_176_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_176\" id=\"quform_1_176_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_176 quform-field-1_176_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_1_176_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_176_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_176\" id=\"quform_1_176_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_176 quform-field-1_176_5\" value=\"A veces\" \/><label for=\"quform_1_176_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_176_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_176\" id=\"quform_1_176_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_176 quform-field-1_176_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_1_176_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_176_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_176\" id=\"quform_1_176_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_176 quform-field-1_176_8\" value=\"A diario\" \/><label for=\"quform_1_176_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_176_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_177 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_177\"><label class=\"quform-label-text\" id=\"quform_1_177_d2e8c1_label\">Mientras duerme, \u00bftiene movimientos continuos o bruscos con las piernas?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_177\"><div class=\"quform-input quform-input-radio quform-input-1_177 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_177_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_177\" id=\"quform_1_177_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_177 quform-field-1_177_1\" value=\"Nunca o casi nunca\" \/><label for=\"quform_1_177_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_177_1\"><span class=\"quform-option-text\">Nunca o casi nunca<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_177\" id=\"quform_1_177_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_177 quform-field-1_177_5\" value=\"A veces\" \/><label for=\"quform_1_177_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_177_5\"><span class=\"quform-option-text\">A veces<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_177\" id=\"quform_1_177_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_177 quform-field-1_177_6\" value=\"2 veces o m\u00e1s a la semana\" \/><label for=\"quform_1_177_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_177_6\"><span class=\"quform-option-text\">2 veces o m\u00e1s a la semana<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_177\" id=\"quform_1_177_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_177 quform-field-1_177_8\" value=\"A diario\" \/><label for=\"quform_1_177_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_177_8\"><span class=\"quform-option-text\">A diario<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_102 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_102\"><label class=\"quform-label-text\" for=\"quform_1_102_d2e8c1\">Otros signos o s\u00edntomas que desee registrar<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_102\"><div class=\"quform-input quform-input-textarea quform-input-1_102 quform-cf\"><textarea id=\"quform_1_102_d2e8c1\" name=\"quform_1_102\" class=\"quform-field quform-field-textarea quform-field-1_102\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_178 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Valoraci\u00f3n de la Somnolencia<\/strong><\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_179 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_179\"><label class=\"quform-label-text\" id=\"quform_1_179_d2e8c1_label\">Excesiva Somnolencia Diurna (ESD). \u00bfPresenta excesiva Somnolencia Diurna? <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_179\"><div class=\"quform-input quform-input-radio quform-input-1_179 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_179_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_179\" id=\"quform_1_179_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_179 quform-field-1_179_1\" value=\"No\" \/><label for=\"quform_1_179_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_179_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_179\" id=\"quform_1_179_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_179 quform-field-1_179_5\" value=\"Leve (Episodios de somnolencia mientras se encuentra en situaciones pasivas: viendo la televisi\u00f3n, leer en cama al anochecer, mientras viaja como pasajero etc.).\" \/><label for=\"quform_1_179_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_179_5\"><span class=\"quform-option-text\">Leve (Episodios de somnolencia mientras se encuentra en situaciones pasivas: viendo la televisi\u00f3n, leer en cama al anochecer, mientras viaja como pasajero etc.).<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_179\" id=\"quform_1_179_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_179 quform-field-1_179_6\" value=\"Moderada (Episodios de somnolencia que se dan en situaciones  donde se requiere cierto grado de atenci\u00f3n, situaciones activas: en el culto o misa, un concierto,  reuni\u00f3n, cine, etc.).\" \/><label for=\"quform_1_179_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_179_6\"><span class=\"quform-option-text\">Moderada (Episodios de somnolencia que se dan en situaciones  donde se requiere cierto grado de atenci\u00f3n, situaciones activas: en el culto o misa, un concierto,  reuni\u00f3n, cine, etc.).<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_179\" id=\"quform_1_179_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_179 quform-field-1_179_8\" value=\"Grave (Episodios de somnolencia diario que se dan en situaciones muy activas: Comer,  estar de pie, hablar\u2026etc). \" \/><label for=\"quform_1_179_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_179_8\"><span class=\"quform-option-text\">Grave (Episodios de somnolencia diario que se dan en situaciones muy activas: Comer,  estar de pie, hablar\u2026etc). <\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_180 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_180\"><label class=\"quform-label-text\" id=\"quform_1_180_d2e8c1_label\">Somnolencia mientras maneja.  \u00bfPresenta somnolencia mientras maneja?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_180\"><div class=\"quform-input quform-input-radio quform-input-1_180 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_180_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_1\" value=\"No\" \/><label for=\"quform_1_180_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_180_1\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_5\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_5\" value=\"Es raro\" \/><label for=\"quform_1_180_d2e8c1_5\" class=\"quform-option-label quform-option-label-1_180_5\"><span class=\"quform-option-text\">Es raro<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_6\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_6\" value=\"Frecuentemente, al medio d\u00eda. \" \/><label for=\"quform_1_180_d2e8c1_6\" class=\"quform-option-label quform-option-label-1_180_6\"><span class=\"quform-option-text\">Frecuentemente, al medio d\u00eda. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_8\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_8\" value=\"Frecuentemente, pero no s\u00f3lo al medio d\u00eda. \" \/><label for=\"quform_1_180_d2e8c1_8\" class=\"quform-option-label quform-option-label-1_180_8\"><span class=\"quform-option-text\">Frecuentemente, pero no s\u00f3lo al medio d\u00eda. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_9\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_9\" value=\"Siempre, especialmente si son trayectos de m\u00e1s de 30-40 minutos. \" \/><label for=\"quform_1_180_d2e8c1_9\" class=\"quform-option-label quform-option-label-1_180_9\"><span class=\"quform-option-text\">Siempre, especialmente si son trayectos de m\u00e1s de 30-40 minutos. <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_180\" id=\"quform_1_180_d2e8c1_10\" class=\"quform-field quform-field-radio quform-field-1_180 quform-field-1_180_10\" value=\"Siempre, incluso en trayectos menores de 30 minutos.\" \/><label for=\"quform_1_180_d2e8c1_10\" class=\"quform-option-label quform-option-label-1_180_10\"><span class=\"quform-option-text\">Siempre, incluso en trayectos menores de 30 minutos.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_183 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_181 quform-cf\"><div class=\"quform-spacer\"><h4><strong>Escala de Somnolencia -test- de Epworth<\/strong><\/h4><br \/>\n<span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">El test de Epworth, es una forma de diagn\u00f3stico de presunci\u00f3n, sencilla y objetiva para medir la <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Excesiva Somnolencia Diurna (ESD).<\/b><\/span><\/span><br \/>\n<br \/>\n<span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">Por favor, complete las preguntas en funci\u00f3n de la frecuencia que padece la <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Somnolencia <\/b><\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">en las siguientes situaciones. Si no hubiera realizado recientemente algunas de estas actividades, imagine c\u00f3mo le hubiese afectado la misma.<\/span><\/span><br \/>\n<h6><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\">\u00bfQu\u00e9 posibilidad existe de que se quedara dormido\/a o adormilase, en las siguientes situaciones? <\/span><\/span><span style=\"font-family: Arial, serif;\"><span style=\"font-size: small;\"><b>Este test no se refiere a estar cansado.<\/b><\/span><\/span><\/h6><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_182 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_182\"><label class=\"quform-label-text\" id=\"quform_1_182_d2e8c1_label\"> Sentado leyendo  <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_182\"><div class=\"quform-input quform-input-radio quform-input-1_182 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_182_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_182\" id=\"quform_1_182_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_182 quform-field-1_182_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_182_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_182_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_182\" id=\"quform_1_182_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_182 quform-field-1_182_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_182_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_182_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_182\" id=\"quform_1_182_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_182 quform-field-1_182_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_182_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_182_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_182\" id=\"quform_1_182_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_182 quform-field-1_182_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_182_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_182_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_200 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_200\"><label class=\"quform-label-text\" id=\"quform_1_200_d2e8c1_label\">Viendo   la televisi\u00f3n<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_200\"><div class=\"quform-input quform-input-radio quform-input-1_200 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_200_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_200\" id=\"quform_1_200_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_200 quform-field-1_200_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_200_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_200_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_200\" id=\"quform_1_200_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_200 quform-field-1_200_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_200_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_200_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_200\" id=\"quform_1_200_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_200 quform-field-1_200_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_200_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_200_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_200\" id=\"quform_1_200_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_200 quform-field-1_200_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_200_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_200_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_201 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_201\"><label class=\"quform-label-text\" id=\"quform_1_201_d2e8c1_label\">Sentado inactivo en un lugar p\u00fablico (conferencia, teatro, cine,  reuni\u00f3n social, culto o misa)   <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_201\"><div class=\"quform-input quform-input-radio quform-input-1_201 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_201_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_201\" id=\"quform_1_201_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_201 quform-field-1_201_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_201_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_201_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_201\" id=\"quform_1_201_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_201 quform-field-1_201_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_201_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_201_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_201\" id=\"quform_1_201_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_201 quform-field-1_201_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_201_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_201_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_201\" id=\"quform_1_201_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_201 quform-field-1_201_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_201_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_201_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_202 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_202\"><label class=\"quform-label-text\" id=\"quform_1_202_d2e8c1_label\">Como pasajero de un carro o autob\u00fas  <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_202\"><div class=\"quform-input quform-input-radio quform-input-1_202 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_202_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_202\" id=\"quform_1_202_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_202 quform-field-1_202_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_202_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_202_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_202\" id=\"quform_1_202_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_202 quform-field-1_202_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_202_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_202_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_202\" id=\"quform_1_202_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_202 quform-field-1_202_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_202_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_202_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_202\" id=\"quform_1_202_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_202 quform-field-1_202_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_202_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_202_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_203 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_203\"><label class=\"quform-label-text\" id=\"quform_1_203_d2e8c1_label\">Recostado, descansando por la tarde <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_203\"><div class=\"quform-input quform-input-radio quform-input-1_203 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_203_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_203\" id=\"quform_1_203_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_203 quform-field-1_203_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_203_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_203_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_203\" id=\"quform_1_203_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_203 quform-field-1_203_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_203_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_203_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_203\" id=\"quform_1_203_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_203 quform-field-1_203_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_203_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_203_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_203\" id=\"quform_1_203_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_203 quform-field-1_203_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_203_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_203_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_204 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_204\"><label class=\"quform-label-text\" id=\"quform_1_204_d2e8c1_label\">Sentado,  hablando con otra persona    <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_204\"><div class=\"quform-input quform-input-radio quform-input-1_204 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_204_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_204\" id=\"quform_1_204_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_204 quform-field-1_204_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_204_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_204_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_204\" id=\"quform_1_204_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_204 quform-field-1_204_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_204_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_204_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_204\" id=\"quform_1_204_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_204 quform-field-1_204_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_204_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_204_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_204\" id=\"quform_1_204_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_204 quform-field-1_204_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_204_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_204_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_205 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_205\"><label class=\"quform-label-text\" id=\"quform_1_205_d2e8c1_label\">Sentado tranquilamente despu\u00e9s de la comida, sin haber tomado alcohol <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_205\"><div class=\"quform-input quform-input-radio quform-input-1_205 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_205_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_205\" id=\"quform_1_205_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_205 quform-field-1_205_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_205_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_205_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_205\" id=\"quform_1_205_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_205 quform-field-1_205_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_205_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_205_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_205\" id=\"quform_1_205_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_205 quform-field-1_205_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_205_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_205_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_205\" id=\"quform_1_205_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_205 quform-field-1_205_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_205_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_205_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_206 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_206\"><label class=\"quform-label-text\" id=\"quform_1_206_d2e8c1_label\">Manejando, cuando se detiene unos  minutos por razones de tr\u00e1fico (atasco, cambio del sem\u00e1foro etc.) <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_206\"><div class=\"quform-input quform-input-radio quform-input-1_206 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_206_d2e8c1_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_206\" id=\"quform_1_206_d2e8c1_1\" class=\"quform-field quform-field-radio quform-field-1_206 quform-field-1_206_1\" value=\"Nunca se adormilar\u00eda\" \/><label for=\"quform_1_206_d2e8c1_1\" class=\"quform-option-label quform-option-label-1_206_1\"><span class=\"quform-option-text\">Nunca se adormilar\u00eda<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_206\" id=\"quform_1_206_d2e8c1_2\" class=\"quform-field quform-field-radio quform-field-1_206 quform-field-1_206_2\" value=\"Pocas posibilidades de adormilarse\" \/><label for=\"quform_1_206_d2e8c1_2\" class=\"quform-option-label quform-option-label-1_206_2\"><span class=\"quform-option-text\">Pocas posibilidades de adormilarse<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_206\" id=\"quform_1_206_d2e8c1_3\" class=\"quform-field quform-field-radio quform-field-1_206 quform-field-1_206_3\" value=\"Es posible que se adormilase\" \/><label for=\"quform_1_206_d2e8c1_3\" class=\"quform-option-label quform-option-label-1_206_3\"><span class=\"quform-option-text\">Es posible que se adormilase<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_206\" id=\"quform_1_206_d2e8c1_4\" class=\"quform-field quform-field-radio quform-field-1_206 quform-field-1_206_4\" value=\"Grandes posibilidades de adormilarse\" \/><label for=\"quform_1_206_d2e8c1_4\" class=\"quform-option-label quform-option-label-1_206_4\"><span class=\"quform-option-text\">Grandes posibilidades de adormilarse<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_103 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_103\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-1_103\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Siguiente<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-207 quform-page-1_207 quform-cf quform-group-style-plain quform-last-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_209 quform-cf\"><div class=\"quform-spacer\"><h3 style=\"text-align: center;\">Muchas gracias por completar el formulario.<\/h3>\n<p style=\"text-align: center;\">Ahora, tan solo debe pulsar sobre el bot\u00f3n <b>SEND <\/b>y esperar a que nos pongamos en contacto con usted para informarle de sus opciones de consulta.<\/p><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_208 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-1_208\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Volver<\/span><\/button><\/div><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-1_208\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">SOLICITAR CONSULTA<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-tree\"><label for=\"quform_1_0_d2e8c1\">This field should be left blank<\/label><input type=\"text\" id=\"quform_1_0_d2e8c1\" name=\"quform_1_0\" class=\"quform-field quform-field-tree quform-field-1_0\" tabindex=\"-1\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/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","protected":false},"excerpt":{"rendered":"<p>IF YOU NEED A CONSULTATION Request a consultation with VIDAIR&#8217;s specialists using the form below. After receiving your request, our team will contact you to arrange the appointment. If you need consultation for sleep disorder, please invest 15 minutes of your time to fill in the following questionnaire. All your personal data will be treated [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_joinchat":[],"footnotes":""},"class_list":["post-3084","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>CONSULTATION - Vidair - Respiratory patient care<\/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:\/\/vidairsalud.com\/en\/consultation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CONSULTATION - Vidair - Respiratory patient care\" \/>\n<meta property=\"og:description\" content=\"IF YOU NEED A CONSULTATION Request a consultation with VIDAIR&#8217;s specialists using the form below. After receiving your request, our team will contact you to arrange the appointment. If you need consultation for sleep disorder, please invest 15 minutes of your time to fill in the following questionnaire. 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