{"id":12,"date":"2019-04-15T20:37:09","date_gmt":"2019-04-15T20:37:09","guid":{"rendered":"http:\/\/driscoll.gomohealth.care\/child-hra\/"},"modified":"2023-11-20T15:54:06","modified_gmt":"2023-11-20T15:54:06","slug":"child-hra","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/child-hra\/","title":{"rendered":"Child HRA"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_57' style='display:none'><div id='gf_57' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_57' id='gform_57'  action='\/es\/wp-json\/wp\/v2\/pages\/12#gf_57' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_57\" \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_57' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_57_1\"  class=\"gfield mt_25 gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_1\"><p>Bienvenido al Driscoll Health Plan. Responda las siguientes preguntas sobre el riesgo de salud sobre este ni\u00f1o para que podamos brindarle la mayor asistencia posible.<\/p>\n\n<p><b><span style=\"color: #790000;\">*<\/span> = requerido<\/b><\/p><\/li><li id=\"field_57_2\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_57_2\"><label class='gfield_label gfield_label_before_complex'  >Nombre del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_57_2'>\n                            \n                            <span id='input_57_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_57_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_57_2_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_57_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_57_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_57_2_6' >Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_57_24\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_24\"><label class='gfield_label gfield_label_before_complex'  >Padre, madre o tutor:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_57_24'>\n                            \n                            <span id='input_57_24_3_container' class='name_first' >\n                                                    <input type='text' name='input_24.3' id='input_57_24_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_57_24_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_57_24_6_container' class='name_last' >\n                                                    <input type='text' name='input_24.6' id='input_57_24_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_57_24_6' >Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_57_25\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_25\"><label class='gfield_label' for='input_57_25' >ID de miembro o SSN:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_57_25' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_23\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_23\"><label class='gfield_label' for='input_57_23' >Fecha de Nacimiento del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_57_23' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_57_23_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_57_23_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_57_23' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_57_26\"  class=\"gfield gfield_contains_required gfield_calculation field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_26\"><label class='gfield_label' for='input_57_26' >Edad:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_57_26' type='text'    value='' class='medium'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_57_27\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_27\"><label class='gfield_label' for='input_57_27' >Direcci\u00f3n del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_57_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_28\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_28\"><label class='gfield_label' for='input_57_28' >Direcci\u00f3n del miembro 2:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_57_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_29\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_29\"><label class='gfield_label' for='input_57_29' >Ciudad del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_57_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_30\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_30\"><label class='gfield_label' for='input_57_30' >Estado del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_57_30' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Seleccione -<\/option><option value='Texas' selected='selected'>Texas<\/option><\/select><\/div><\/li><li id=\"field_57_32\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_32\"><label class='gfield_label' for='input_57_32' >C\u00f3digo postal del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_57_32' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_33\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_33\"><label class='gfield_label' for='input_57_33' >Nombre del PCP:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_57_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_11\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_11\"><label class='gfield_label'  >\u00bfC\u00f3mo es la salud general del miembro?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_11'>\n\t\t\t<li class='gchoice gchoice_57_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Excellent'  id='choice_57_11_0'    \/>\n\t\t\t\t<label for='choice_57_11_0' id='label_57_11_0'>Excelente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Good'  id='choice_57_11_1'    \/>\n\t\t\t\t<label for='choice_57_11_1' id='label_57_11_1'>Bueno<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Poor'  id='choice_57_11_2'    \/>\n\t\t\t\t<label for='choice_57_11_2' id='label_57_11_2'>Pobre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Very poor'  id='choice_57_11_3'    \/>\n\t\t\t\t<label for='choice_57_11_3' id='label_57_11_3'>Muy mala<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_34\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_34\"><label class='gfield_label' for='input_57_34' >Anote las condiciones de salud MALAS o MUY MALAS:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_57_34' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_57_4\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_4\"><label class='gfield_label'  >\u00bfEl miembro necesita equipo especial para caminar, hablar, o\u00edr, respirar o alimentar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_4'>\n\t\t\t<li class='gchoice gchoice_57_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Yes'  id='choice_57_4_0'    \/>\n\t\t\t\t<label for='choice_57_4_0' id='label_57_4_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='No'  id='choice_57_4_1'    \/>\n\t\t\t\t<label for='choice_57_4_1' id='label_57_4_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_35\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_35\"><label class='gfield_label' for='input_57_35' >\u00bfQu\u00e9 equipo?:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_57_35' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_57_36\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_36\"><label class='gfield_label'  >\u00bfSu familia viaja por trabajo agr\u00edcola?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_36'>\n\t\t\t<li class='gchoice gchoice_57_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_57_36_0'    \/>\n\t\t\t\t<label for='choice_57_36_0' id='label_57_36_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_57_36_1'    \/>\n\t\t\t\t<label for='choice_57_36_1' id='label_57_36_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_37\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_37\"><label class='gfield_label' for='input_57_37' >\u00bfad\u00f3nde viaja?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_57_37' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_38\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_38\"><label class='gfield_label'  >\u00bfLa condici\u00f3n de salud del miembro es mala o muy mala?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_38'>\n\t\t\t<li class='gchoice gchoice_57_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Yes'  id='choice_57_38_0'    \/>\n\t\t\t\t<label for='choice_57_38_0' id='label_57_38_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='No'  id='choice_57_38_1'    \/>\n\t\t\t\t<label for='choice_57_38_1' id='label_57_38_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_39\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_39\"><label class='gfield_label' for='input_57_39' >Anote las condiciones de salud MALAS o MUY MALAS:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_57_39' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_57_40\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_40\"><label class='gfield_label gfield_label_before_complex'  >\u00bfTiene el miembro actualmente alg\u00fan problema de salud?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_57_40'><li class='gchoice gchoice_57_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Heart'  id='choice_57_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_1' id='label_57_40_1'>Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Cancer'  id='choice_57_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_2' id='label_57_40_2'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Bleeding'  id='choice_57_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_3' id='label_57_40_3'>Sangrado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Diabetes'  id='choice_57_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_4' id='label_57_40_4'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='Kidney'  id='choice_57_40_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_5' id='label_57_40_5'>Ri\u00f1\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.6' type='checkbox'  value='COPD'  id='choice_57_40_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_6' id='label_57_40_6'>COPD\/EPOC<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.7' type='checkbox'  value='Cystic Fibrosis'  id='choice_57_40_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_7' id='label_57_40_7'>Fibrosis qu\u00edstica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.8' type='checkbox'  value='HIV or AIDS'  id='choice_57_40_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_8' id='label_57_40_8'>VIH\/sida<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.9' type='checkbox'  value='Mental Health'  id='choice_57_40_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_9' id='label_57_40_9'>Salud mental<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.11' type='checkbox'  value='Depression'  id='choice_57_40_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_11' id='label_57_40_11'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.12' type='checkbox'  value='Eating Disorders'  id='choice_57_40_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_12' id='label_57_40_12'>Trastornos de la alimentaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.13' type='checkbox'  value='Substance Misuse'  id='choice_57_40_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_13' id='label_57_40_13'>Abuso de sustancias<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_57_40_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.14' type='checkbox'  value='Other health problems'  id='choice_57_40_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_57_40_14' id='label_57_40_14'>Otros problemas de salud<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_41\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_41\"><label class='gfield_label' for='input_57_41' >Por favor enumere otros problemas de salud:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_57_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_57_5\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_5\"><label class='gfield_label'  >En los \u00faltimos 90 d\u00edas, \u00bfha hecho el miembro 3 visitas a una sala de emergencias o ha sido admitido 1 vez por problemas de diabetes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_5'>\n\t\t\t<li class='gchoice gchoice_57_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Yes'  id='choice_57_5_0'    \/>\n\t\t\t\t<label for='choice_57_5_0' id='label_57_5_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='No'  id='choice_57_5_1'    \/>\n\t\t\t\t<label for='choice_57_5_1' id='label_57_5_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_6\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_6\"><label class='gfield_label'  >En los \u00faltimos 90 d\u00edas, \u00bfha hecho el miembro 3 visitas a una sala de emergencias o ha sido admitido 1 vez por problemas de asma?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_6'>\n\t\t\t<li class='gchoice gchoice_57_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Yes'  id='choice_57_6_0'    \/>\n\t\t\t\t<label for='choice_57_6_0' id='label_57_6_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='No'  id='choice_57_6_1'    \/>\n\t\t\t\t<label for='choice_57_6_1' id='label_57_6_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_42\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_42\"><label class='gfield_label'  >\u00bfLa afiliada est\u00e1 embarazada?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_42'>\n\t\t\t<li class='gchoice gchoice_57_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_57_42_0'    \/>\n\t\t\t\t<label for='choice_57_42_0' id='label_57_42_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_57_42_1'    \/>\n\t\t\t\t<label for='choice_57_42_1' id='label_57_42_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_49\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_49\"><label class='gfield_label'  >\u00bfEl representante del miembro tiene un dentista?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_49'>\n\t\t\t<li class='gchoice gchoice_57_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_57_49_0'    \/>\n\t\t\t\t<label for='choice_57_49_0' id='label_57_49_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_57_49_1'    \/>\n\t\t\t\t<label for='choice_57_49_1' id='label_57_49_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_50\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_50\"><label class='gfield_label'  >\u00bfEl representante del miembro tiene antecedentes de caries?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_50'>\n\t\t\t<li class='gchoice gchoice_57_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_57_50_0'    \/>\n\t\t\t\t<label for='choice_57_50_0' id='label_57_50_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_57_50_1'    \/>\n\t\t\t\t<label for='choice_57_50_1' id='label_57_50_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_43\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_43\"><p style=\"font-size: 22px; font-weight: bold;\">Condiciones de vivienda<\/p><\/li><li id=\"field_57_12\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_12\"><label class='gfield_label'  >\u00bfCu\u00e1l es tu situaci\u00f3n de hogar a partir de hoy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_12'>\n\t\t\t<li class='gchoice gchoice_57_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Rent'  id='choice_57_12_0'    \/>\n\t\t\t\t<label for='choice_57_12_0' id='label_57_12_0'>Alquila<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Own'  id='choice_57_12_1'    \/>\n\t\t\t\t<label for='choice_57_12_1' id='label_57_12_1'>Due\u00f1o\/a<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Live with a relative\/friend'  id='choice_57_12_2'    \/>\n\t\t\t\t<label for='choice_57_12_2' id='label_57_12_2'>Vive con pariente\/amigo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_13\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_13\"><label class='gfield_label'  >En su vivienda, \u00bftiene alg\u00fan problema como plagas, moho, p\u00e9rdidas, etc?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_13'>\n\t\t\t<li class='gchoice gchoice_57_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_57_13_0'    \/>\n\t\t\t\t<label for='choice_57_13_0' id='label_57_13_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_57_13_1'    \/>\n\t\t\t\t<label for='choice_57_13_1' id='label_57_13_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_14\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_14\"><label class='gfield_label' for='input_57_14' >Por favor liste los problemas por aqu\u00ed:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_57_14' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_57_44\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_44\"><p style=\"font-size: 22px; font-weight: bold;\">Comida<\/p><\/li><li id=\"field_57_15\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_15\"><label class='gfield_label'  >En los \u00faltimos 12 meses, le preocupaba que se le acabara la comida antes de tener dinero para comprar m\u00e1s.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_15'>\n\t\t\t<li class='gchoice gchoice_57_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Often true'  id='choice_57_15_0'    \/>\n\t\t\t\t<label for='choice_57_15_0' id='label_57_15_0'>A menudo es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Sometimes true'  id='choice_57_15_1'    \/>\n\t\t\t\t<label for='choice_57_15_1' id='label_57_15_1'>A veces es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Never true'  id='choice_57_15_2'    \/>\n\t\t\t\t<label for='choice_57_15_2' id='label_57_15_2'>Nunca es cierto<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_16\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_16\"><label class='gfield_label'  >En los \u00faltimos 12 meses, la comida que compr\u00f3 no le dur\u00f3 mucho y no ten\u00eda dinero para comprar m\u00e1s.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_16'>\n\t\t\t<li class='gchoice gchoice_57_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Often true'  id='choice_57_16_0'    \/>\n\t\t\t\t<label for='choice_57_16_0' id='label_57_16_0'>A menudo es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Sometimes true'  id='choice_57_16_1'    \/>\n\t\t\t\t<label for='choice_57_16_1' id='label_57_16_1'>A veces es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Never true'  id='choice_57_16_2'    \/>\n\t\t\t\t<label for='choice_57_16_2' id='label_57_16_2'>Nunca es cierto<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_45\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_45\"><p style=\"font-size: 22px; font-weight: bold;\">Servicios de transporte<\/p><\/li><li id=\"field_57_17\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_17\"><label class='gfield_label'  >\u00bfEn los \u00faltimos 12 meses, \u00bfla falta de transporte confiable le ha impedido acudir a una cita m\u00e9dica, reuniones, trabajar o conseguir las cosas necesarias para la vida diaria?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_17'>\n\t\t\t<li class='gchoice gchoice_57_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_57_17_0'    \/>\n\t\t\t\t<label for='choice_57_17_0' id='label_57_17_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_57_17_1'    \/>\n\t\t\t\t<label for='choice_57_17_1' id='label_57_17_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_46\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_46\"><label class='gfield_label' for='input_57_46' >Indique por favor:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_57_46' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_57_47\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_47\"><p style=\"font-size: 22px; font-weight: bold;\">Servicios p\u00fablicos<\/p><\/li><li id=\"field_57_18\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_18\"><label class='gfield_label'  >\u00bfEn los \u00faltimos 12 meses, \u00bfla compa\u00f1\u00eda de electricidad, gas, petr\u00f3leo o agua ha amenazado con cortar los servicios en su hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_18'>\n\t\t\t<li class='gchoice gchoice_57_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_57_18_0'    \/>\n\t\t\t\t<label for='choice_57_18_0' id='label_57_18_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_57_18_1'    \/>\n\t\t\t\t<label for='choice_57_18_1' id='label_57_18_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='Already shut off'  id='choice_57_18_2'    \/>\n\t\t\t\t<label for='choice_57_18_2' id='label_57_18_2'>Ya est\u00e1 apagado<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_48\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_48\"><p style=\"font-size: 22px; font-weight: bold;\">Seguridad<\/p><\/li><li id=\"field_57_19\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_19\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, lo lastima f\u00edsicamente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_19'>\n\t\t\t<li class='gchoice gchoice_57_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Never'  id='choice_57_19_0'    \/>\n\t\t\t\t<label for='choice_57_19_0' id='label_57_19_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Rarely'  id='choice_57_19_1'    \/>\n\t\t\t\t<label for='choice_57_19_1' id='label_57_19_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_19_2'>\n\t\t\t\t<input name='input_19' type='radio' value='Sometimes'  id='choice_57_19_2'    \/>\n\t\t\t\t<label for='choice_57_19_2' id='label_57_19_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_19_3'>\n\t\t\t\t<input name='input_19' type='radio' value='Fairly often'  id='choice_57_19_3'    \/>\n\t\t\t\t<label for='choice_57_19_3' id='label_57_19_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_19_4'>\n\t\t\t\t<input name='input_19' type='radio' value='Frequently'  id='choice_57_19_4'    \/>\n\t\t\t\t<label for='choice_57_19_4' id='label_57_19_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_20\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_20\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, lo insulta o le habla mal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_20'>\n\t\t\t<li class='gchoice gchoice_57_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Never'  id='choice_57_20_0'    \/>\n\t\t\t\t<label for='choice_57_20_0' id='label_57_20_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Rarely'  id='choice_57_20_1'    \/>\n\t\t\t\t<label for='choice_57_20_1' id='label_57_20_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='Sometimes'  id='choice_57_20_2'    \/>\n\t\t\t\t<label for='choice_57_20_2' id='label_57_20_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_20_3'>\n\t\t\t\t<input name='input_20' type='radio' value='Fairly often'  id='choice_57_20_3'    \/>\n\t\t\t\t<label for='choice_57_20_3' id='label_57_20_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_20_4'>\n\t\t\t\t<input name='input_20' type='radio' value='Frequently'  id='choice_57_20_4'    \/>\n\t\t\t\t<label for='choice_57_20_4' id='label_57_20_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_21\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_21\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, lo amenaza con hacerle da\u00f1o?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_21'>\n\t\t\t<li class='gchoice gchoice_57_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Never'  id='choice_57_21_0'    \/>\n\t\t\t\t<label for='choice_57_21_0' id='label_57_21_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Rarely'  id='choice_57_21_1'    \/>\n\t\t\t\t<label for='choice_57_21_1' id='label_57_21_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='Sometimes'  id='choice_57_21_2'    \/>\n\t\t\t\t<label for='choice_57_21_2' id='label_57_21_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='Fairly often'  id='choice_57_21_3'    \/>\n\t\t\t\t<label for='choice_57_21_3' id='label_57_21_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_21_4'>\n\t\t\t\t<input name='input_21' type='radio' value='Frequently'  id='choice_57_21_4'    \/>\n\t\t\t\t<label for='choice_57_21_4' id='label_57_21_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_57_22\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_57_22\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, le grita o le maldice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_57_22'>\n\t\t\t<li class='gchoice gchoice_57_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Never'  id='choice_57_22_0'    \/>\n\t\t\t\t<label for='choice_57_22_0' id='label_57_22_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Rarely'  id='choice_57_22_1'    \/>\n\t\t\t\t<label for='choice_57_22_1' id='label_57_22_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Sometimes'  id='choice_57_22_2'    \/>\n\t\t\t\t<label for='choice_57_22_2' id='label_57_22_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='Fairly often'  id='choice_57_22_3'    \/>\n\t\t\t\t<label for='choice_57_22_3' id='label_57_22_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_57_22_4'>\n\t\t\t\t<input name='input_22' type='radio' value='Frequently'  id='choice_57_22_4'    \/>\n\t\t\t\t<label for='choice_57_22_4' 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).getTime() );<\/script><\/p><\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_57' id='gform_ajax_frame_57' title='Este iframe contiene la l\u00f3gica necesaria para gestionar formularios con ajax activado.'><\/iframe>\n                <script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 57, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_57').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_57');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_57').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_57').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_57').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_57').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_57').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_57').val();gformInitSpinner( 57, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [57, current_page]);window['gf_submitting_57'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_57').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_57').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [57]);window['gf_submitting_57'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_57').text());}, 50);}else{jQuery('#gform_57').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [57, current_page]);} );} );\n<\/script>\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\" style=\"font-size:12px;margin-top:20px;\"><p><span data-contrast=\"auto\">MSO-004 9\/23<br \/>\n<\/span><span data-contrast=\"auto\">Center for Disease Control and Prevention, (2011<\/span><span data-contrast=\"none\">) Un marco para evaluaciones de riesgos sanitarios centradas en el paciente: proporcionar servicios de promoci\u00f3n de la salud y prevenci\u00f3n de enfermedades a los beneficiarios de Medicare <\/span><a href=\"https:\/\/www.cdc.gov\/policy\/hst\/hra\/FrameworkForHRA.pdf\"><span data-contrast=\"auto\">https:\/\/www.cdc.gov\/policy\/hst\/hra\/FrameworkForHRA.pdf<\/span><\/a><span data-contrast=\"auto\"> <\/span><span data-ccp-props=\"{\"><br \/>\n<\/span><span data-contrast=\"auto\">La herramienta de detecci\u00f3n de necesidades sociales de las comunidades de salud responsables <\/span><a href=\"https:\/\/urldefense.com\/v3\/__https:\/innovation.cms.gov\/files\/worksheets\/ahcm-screeningtool.pdf__;!!N2uLCny5_Q!NL2B_pPhOWgLirWps_aWPvaVandmEIgrPUPsmgLy5duzezVyGzb99NP9Ru8RztGvzkKe%24\"><span data-contrast=\"auto\">https:\/\/innovation.cms.gov\/files\/worksheets\/ahcm-screeningtool.pdf<\/span><\/a><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v19.10 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Child Health Plan Needs Assessment Form | Driscoll Health Plan<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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