{"id":1263,"date":"2024-10-29T10:55:36","date_gmt":"2024-10-29T10:55:36","guid":{"rendered":"https:\/\/driscoll.gomohealth.care\/prenatal-program\/nmdoh-screener\/"},"modified":"2024-10-29T12:10:09","modified_gmt":"2024-10-29T12:10:09","slug":"nmdoh-screener","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/prenatal-program\/nmdoh-screener\/","title":{"rendered":"NMDoH Screener"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1064.96px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" 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_63' style='display:none'><div id='gf_63' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_63' id='gform_63'  action='\/es\/wp-json\/wp\/v2\/pages\/1263#gf_63' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_63\" \/>\n        <div id='gf_progressbar_wrapper_63' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>4<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_63_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_63' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_63_86\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_86\"><div class='ginput_container ginput_container_text'><input name='input_86' id='input_63_86' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_88\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_88\"><div class='ginput_container ginput_container_text'><input name='input_88' id='input_63_88' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_87\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_87\"><div class='ginput_container ginput_container_text'><input name='input_87' id='input_63_87' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_1\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_1\"><div class='ginput_container ginput_container_text'><input name='input_1' id='input_63_1' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_3\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_3\"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_63_3' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_4\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_4\"><div class='ginput_container ginput_container_text'><input name='input_4' id='input_63_4' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_5\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_5\"><div class='ginput_container ginput_container_text'><input name='input_5' id='input_63_5' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/driscoll.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/1263' \/><\/div><\/li><li id=\"field_63_6\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_6\"><div class='ginput_container ginput_container_text'><input name='input_6' id='input_63_6' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_85\"  class=\"gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_85\"><div class='ginput_container ginput_container_text'><input name='input_85' id='input_63_85' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_63_7\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_7\"><p>\u00a1Felicitaciones por la pr\u00f3xima incorporaci\u00f3n a su familia!  Estamos muy entusiasmados de brindarle apoyo mientras comienza esta nueva parte de su vida.<\/p>\n\n<p>En este programa, durante su embarazo le enviaremos cada semana por mensaje de texto 2 o 3 consejos sobre cuidado de la salud. Este programa no reemplaza la atenci\u00f3n de su m\u00e9dico; por el contrario, pretende ser una ayuda.<\/p>\n\n<p>Para asegurarnos de enviarle la informaci\u00f3n que le resultar\u00e1 m\u00e1s \u00fatil, nos gustar\u00eda conocerla mejor.<\/p>\n\n<p>Al completar esta encuesta de cinco minutos, ayudar\u00e1 a Driscoll Health Plan a comprender mejor sus necesidades de atenci\u00f3n m\u00e9dica. Sus respuestas nos ayudar\u00e1n a mejorar nuestros servicios y asegurarnos de que usted reciba la atenci\u00f3n y el apoyo que necesita. \u00a1Su contribuci\u00f3n es muy importante y nos ayudar\u00e1 a servirle!<\/p>\n\n<p>Parte de la informaci\u00f3n de esta encuesta ser\u00e1 utilizada por Driscoll Health Plan para identificar \u00e1reas donde se necesita m\u00e1s ayuda y para recomendar los recursos m\u00e1s adecuados. Esta informaci\u00f3n tambi\u00e9n puede compartirse con la HHSC y se agregar\u00e1 a su expediente de miembro.<\/p>\n\n<p>* indica una respuesta requerida.<\/p><\/li><li id=\"field_63_8\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_8\"><label class='gfield_label gfield_label_before_complex'  >Nombre:<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_63_8'>\n                            \n                            <span id='input_63_8_3_container' class='name_first' >\n                                                    <input type='text' name='input_8.3' id='input_63_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_63_8_3' >Su primer nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_63_8_6_container' class='name_last' >\n                                                    <input type='text' name='input_8.6' id='input_63_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_63_8_6' >Su apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_63_10\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_10\"><label class='gfield_label' for='input_63_10' >No. de ID de 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_10' id='input_63_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_11\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_11\"><label class='gfield_label' for='input_63_11' >N\u00famero de tel\u00e9fono m\u00f3vil:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_63_11' type='text' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_63_12\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_12\"><label class='gfield_label' for='input_63_12' >\u00bfCu\u00e1l es su fecha de nacimiento?<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_12' id='input_63_12' type='text' value='' class='datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='aaaa\/mm\/dd' aria-describedby=\"input_63_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_63_12_date_format' class='screen-reader-text'>AAAA barra MM barra DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_63_12' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_63_13\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_13\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_13' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_13' id='input_63_13' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_63_14' class='gform_next_button button' value='Contin\u00fae con el paso siguiente'  onclick='jQuery(\"#gform_target_page_number_63\").val(\"2\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_63\").val(\"2\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_63_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_63_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_63_15\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_15\"><span data-gppa-live-merge-tag=\"@{Name:8.3:fallback[Client]}\">Client<\/span>, antes de continuar por favor revise cuidadosamente la siguiente informaci\u00f3n: <\/li><li id=\"field_63_16\"  class=\"gfield gfield--width-full copy-16-to-30 gwcopy gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_63_16\"><label class='gfield_label gfield_label_before_complex'  >Consentimiento informado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_63_16'><li class='gchoice gchoice_63_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='1) Participation in this screening is voluntary and will not affect your status as a Member of the Driscoll Health Plan.'  id='choice_63_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_16_1' id='label_63_16_1'>1) La participaci\u00f3n en esta encuesta es voluntaria y no afectar\u00e1 su condici\u00f3n de miembro de Driscoll Health Plan.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='2) The purpose of this screening is to find opportunities for Driscoll Health Plan to provide you with additional resources that may positively impact your health, safety, and overall well-being. The data collected will be based on questions related to non-medical topics in life that may impact your health.'  id='choice_63_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_16_2' id='label_63_16_2'>2) El prop\u00f3sito de esta evaluaci\u00f3n es encontrar oportunidades para que Driscoll Health Plan le brinde recursos adicionales que puedan tener un impacto positivo en su salud, su seguridad y su bienestar general. Los datos recopilados se basar\u00e1n en preguntas relacionadas con temas no m\u00e9dicos de la vida que podr\u00edan afectar su salud.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='3) The data collected in this screening will be used by Driscoll Health Plan to identify areas of need and in determining appropriate resources for referral. Data collected may also be shared with the Health and Human Services Commission (HHSC), and the screening will be a part of the Member Record.'  id='choice_63_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_16_3' id='label_63_16_3'>3) Los datos recopilados en esta encuesta ser\u00e1n utilizados por Driscoll Health Plan para identificar \u00e1reas de necesidad y determinar los recursos apropiados para la derivaci\u00f3n. Los datos recopilados tambi\u00e9n pueden compartirse con la Comisi\u00f3n de Salud y Servicios Humanos (HHSC), y la encuesta formar\u00e1 parte del Expediente del Miembro.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_25\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_25\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_25' >C1<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_63_25' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_26\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_26\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_26' >C2<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_63_26' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_27\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_27\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_27' >C3<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_63_27' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_28\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_28\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_28' >ctr<\/label><div class='ginput_container ginput_container_number'><input name='input_28' id='input_63_28' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_63_20' class='gform_previous_button button' value='Previo'  onclick='jQuery(\"#gform_target_page_number_63\").val(\"1\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_63\").val(\"1\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_63_20' class='gform_next_button button' value='Contin\u00fae con el paso siguiente'  onclick='jQuery(\"#gform_target_page_number_63\").val(\"3\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_63\").val(\"3\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_63_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_63_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_63_21\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_21\">Parece que no has seleccionado todas las casillas de consentimiento requeridas. Para continuar, revise y confirme su consentimiento seleccionando las tres primeras opciones a continuaci\u00f3n.<\/li><li id=\"field_63_30\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_63_30\"><label class='gfield_label gfield_label_before_complex'  >Consentimiento informado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_63_30'><li class='gchoice gchoice_63_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='1) Participation in this screening is voluntary and will not affect your status as a Member of the Driscoll Health Plan.'  id='choice_63_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_30_1' id='label_63_30_1'>1) La participaci\u00f3n en esta encuesta es voluntaria y no afectar\u00e1 su condici\u00f3n de miembro de Driscoll Health Plan.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='2) The purpose of this screening is to find opportunities for Driscoll Health Plan to provide you with additional resources that may positively impact your health, safety, and overall well-being. The data collected will be based on questions related to non-medical topics in life that may impact your health.'  id='choice_63_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_30_2' id='label_63_30_2'>2) El prop\u00f3sito de esta evaluaci\u00f3n es encontrar oportunidades para que Driscoll Health Plan le brinde recursos adicionales que puedan tener un impacto positivo en su salud, su seguridad y su bienestar general. Los datos recopilados se basar\u00e1n en preguntas relacionadas con temas no m\u00e9dicos de la vida que podr\u00edan afectar su salud.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='3) The data collected in this screening will be used by Driscoll Health Plan to identify areas of need and in determining appropriate resources for referral. Data collected may also be shared with the Health and Human Services Commission (HHSC), and the screening will be a part of the Member Record.'  id='choice_63_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_30_3' id='label_63_30_3'>3) Los datos recopilados en esta encuesta ser\u00e1n utilizados por Driscoll Health Plan para identificar \u00e1reas de necesidad y determinar los recursos apropiados para la derivaci\u00f3n. Los datos recopilados tambi\u00e9n pueden compartirse con la Comisi\u00f3n de Salud y Servicios Humanos (HHSC), y la encuesta formar\u00e1 parte del Expediente del Miembro.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_32\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_32' >C1_2B<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_63_32' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_33\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_33\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_33' >C2_2B<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_63_33' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_34\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_34\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_34' >C3_2B<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_63_34' type='text' value='1' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_35\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_35\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_35' >ctr_2B<\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_63_35' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_63_31\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_63_31\"><label class='gfield_label gfield_label_before_complex'  >Information_Remain_With_Driscoll<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_63_31'><li class='gchoice gchoice_63_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='I wish to have my information remain within Driscoll Health Plan.'  id='choice_63_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_31_1' id='label_63_31_1'>Deseo que mi informaci\u00f3n permanezca dentro del Driscoll Health Plan.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_63_24' class='gform_previous_button button' value='Previo'  onclick='jQuery(\"#gform_target_page_number_63\").val(\"2\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_63\").val(\"2\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_63_24' class='gform_next_button button' value='Contin\u00fae con el paso siguiente'  onclick='jQuery(\"#gform_target_page_number_63\").val(\"4\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_63\").val(\"4\");  jQuery(\"#gform_63\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_63_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_63_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_63_29\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_29\">Estas preguntas son opcionales, pero le recomendamos compartir toda la informaci\u00f3n que no le cause incomodidad. Esto ayudar\u00e1 a Driscoll Health Plan a brindarle un mejor servicio.<\/li><li id=\"field_63_36\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_36\"><h2 class=\"gsection_title\">Comida<\/h2><div class='gsection_description' id='gfield_description_63_36'>Responda si las declaraciones ocurrieron A MENUDO, A VECES o NUNCA para usted y su hogar en los \u00faltimos 12 meses.<\/div><\/li><li id=\"field_63_37\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_37\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfle preocupaba que la comida se le acabara antes de tener dinero para comprar m\u00e1s?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_37'>\n\t\t\t<li class='gchoice gchoice_63_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Often true'  id='choice_63_37_0'    \/>\n\t\t\t\t<label for='choice_63_37_0' id='label_63_37_0'>A menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='Sometimes true'  id='choice_63_37_1'    \/>\n\t\t\t\t<label for='choice_63_37_1' id='label_63_37_1'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_37_2'>\n\t\t\t\t<input name='input_37' type='radio' value='Never true'  id='choice_63_37_2'    \/>\n\t\t\t\t<label for='choice_63_37_2' id='label_63_37_2'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_37_3'>\n\t\t\t\t<input name='input_37' type='radio' value='Decline to answer'  id='choice_63_37_3'    \/>\n\t\t\t\t<label for='choice_63_37_3' id='label_63_37_3'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_38\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_38\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfla comida que compr\u00f3 no le dur\u00f3 y no ten\u00eda dinero para comprar m\u00e1s?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_38'>\n\t\t\t<li class='gchoice gchoice_63_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Often true'  id='choice_63_38_0'    \/>\n\t\t\t\t<label for='choice_63_38_0' id='label_63_38_0'>A menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='Sometimes true'  id='choice_63_38_1'    \/>\n\t\t\t\t<label for='choice_63_38_1' id='label_63_38_1'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_38_2'>\n\t\t\t\t<input name='input_38' type='radio' value='Never true'  id='choice_63_38_2'    \/>\n\t\t\t\t<label for='choice_63_38_2' id='label_63_38_2'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_38_3'>\n\t\t\t\t<input name='input_38' type='radio' value='Decline to answer'  id='choice_63_38_3'    \/>\n\t\t\t\t<label for='choice_63_38_3' id='label_63_38_3'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_39\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_39\"><label class='gfield_label'  >\u00bfLe gustar\u00eda recibir ayuda con sus necesidades alimentarias?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_39'>\n\t\t\t<li class='gchoice gchoice_63_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_63_39_0'    \/>\n\t\t\t\t<label for='choice_63_39_0' id='label_63_39_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_63_39_1'    \/>\n\t\t\t\t<label for='choice_63_39_1' id='label_63_39_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_39_2'>\n\t\t\t\t<input name='input_39' type='radio' value='Decline to answer'  id='choice_63_39_2'    \/>\n\t\t\t\t<label for='choice_63_39_2' id='label_63_39_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_40\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_40\"><h2 class=\"gsection_title\">Transporte<\/h2><\/li><li id=\"field_63_41\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_41\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfla falta de transporte confiable le ha impedido ir a sus citas m\u00e9dicas u obtener medicamentos?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_41'>\n\t\t\t<li class='gchoice gchoice_63_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_63_41_0'    \/>\n\t\t\t\t<label for='choice_63_41_0' id='label_63_41_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_63_41_1'    \/>\n\t\t\t\t<label for='choice_63_41_1' id='label_63_41_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='Decline to answer'  id='choice_63_41_2'    \/>\n\t\t\t\t<label for='choice_63_41_2' id='label_63_41_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_42\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_42\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfla falta de transporte confiable le ha impedido hacer cosas que necesitaba hacer, como ir de compras o ir al trabajo o a la escuela?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_42'>\n\t\t\t<li class='gchoice gchoice_63_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_63_42_0'    \/>\n\t\t\t\t<label for='choice_63_42_0' id='label_63_42_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_63_42_1'    \/>\n\t\t\t\t<label for='choice_63_42_1' id='label_63_42_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_42_2'>\n\t\t\t\t<input name='input_42' type='radio' value='Decline to answer'  id='choice_63_42_2'    \/>\n\t\t\t\t<label for='choice_63_42_2' id='label_63_42_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_43\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_43\"><label class='gfield_label'  >\u00bfNecesita ayuda con el transporte?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_43'>\n\t\t\t<li class='gchoice gchoice_63_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes'  id='choice_63_43_0'    \/>\n\t\t\t\t<label for='choice_63_43_0' id='label_63_43_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_63_43_1'    \/>\n\t\t\t\t<label for='choice_63_43_1' id='label_63_43_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_43_2'>\n\t\t\t\t<input name='input_43' type='radio' value='Decline to answer'  id='choice_63_43_2'    \/>\n\t\t\t\t<label for='choice_63_43_2' id='label_63_43_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_44\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_44\"><h2 class=\"gsection_title\">Vivienda<\/h2><\/li><li id=\"field_63_45\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_45\"><label class='gfield_label'  >\u00bfCu\u00e1l es hoy su condici\u00f3n de vivienda?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_45'>\n\t\t\t<li class='gchoice gchoice_63_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='I have a steady place to live.'  id='choice_63_45_0'    \/>\n\t\t\t\t<label for='choice_63_45_0' id='label_63_45_0'>Tengo un lugar estable para vivir.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='I have a steady place to live today, but I\u2019m worried about losing it in the future.'  id='choice_63_45_1'    \/>\n\t\t\t\t<label for='choice_63_45_1' id='label_63_45_1'>Hoy tengo un lugar estable para vivir, pero me preocupa perderlo en el futuro.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_45_2'>\n\t\t\t\t<input name='input_45' type='radio' value='I don\u2019t have a steady place to live. I am temporarily staying in another person\u2019s home, in a hotel, shelter, car, abandoned building, bus or train station, or living outside on the street, in the woods, or in a park.'  id='choice_63_45_2'    \/>\n\t\t\t\t<label for='choice_63_45_2' id='label_63_45_2'>No tengo un lugar estable para vivir. Me estoy quedando temporalmente en casa de otra persona, en un hotel, refugio, autom\u00f3vil, edificio abandonado, estaci\u00f3n de autob\u00fas o tren, o vivo en la calle, un bosque o un parque.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_45_3'>\n\t\t\t\t<input name='input_45' type='radio' value='Decline to answer'  id='choice_63_45_3'    \/>\n\t\t\t\t<label for='choice_63_45_3' id='label_63_45_3'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_46\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_46\"><strong><em>Cuando responda las seis preguntas siguientes piense en el lugar donde vive.<\/em><\/strong><\/li><li id=\"field_63_47\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_47\"><label class='gfield_label'  >\u00bfTiene problemas para pagar servicios como electricidad, gas, calefacci\u00f3n, aire acondicionado o agua?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_47'>\n\t\t\t<li class='gchoice gchoice_63_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_63_47_0'    \/>\n\t\t\t\t<label for='choice_63_47_0' id='label_63_47_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_63_47_1'    \/>\n\t\t\t\t<label for='choice_63_47_1' id='label_63_47_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Decline to answer'  id='choice_63_47_2'    \/>\n\t\t\t\t<label for='choice_63_47_2' id='label_63_47_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_48\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_48\"><label class='gfield_label'  >\u00bfTiene problemas con servicios que no funcionan, como electricidad, gas, calefacci\u00f3n, aire acondicionado o agua?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_48'>\n\t\t\t<li class='gchoice gchoice_63_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_63_48_0'    \/>\n\t\t\t\t<label for='choice_63_48_0' id='label_63_48_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_63_48_1'    \/>\n\t\t\t\t<label for='choice_63_48_1' id='label_63_48_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Decline to answer'  id='choice_63_48_2'    \/>\n\t\t\t\t<label for='choice_63_48_2' id='label_63_48_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_49\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_49\"><label class='gfield_label'  >\u00bfTienes problemas con plagas como insectos o ratones?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_49'>\n\t\t\t<li class='gchoice gchoice_63_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_63_49_0'    \/>\n\t\t\t\t<label for='choice_63_49_0' id='label_63_49_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_63_49_1'    \/>\n\t\t\t\t<label for='choice_63_49_1' id='label_63_49_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_49_2'>\n\t\t\t\t<input name='input_49' type='radio' value='Decline to answer'  id='choice_63_49_2'    \/>\n\t\t\t\t<label for='choice_63_49_2' id='label_63_49_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_50\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_50\"><label class='gfield_label'  >\u00bfTienes problemas con el moho?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_50'>\n\t\t\t<li class='gchoice gchoice_63_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_63_50_0'    \/>\n\t\t\t\t<label for='choice_63_50_0' id='label_63_50_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_63_50_1'    \/>\n\t\t\t\t<label for='choice_63_50_1' id='label_63_50_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_50_2'>\n\t\t\t\t<input name='input_50' type='radio' value='Decline to answer'  id='choice_63_50_2'    \/>\n\t\t\t\t<label for='choice_63_50_2' id='label_63_50_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_51\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_51\"><label class='gfield_label'  >\u00bfTiene problemas con pinturas o tuber\u00edas con plomo?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_51'>\n\t\t\t<li class='gchoice gchoice_63_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Yes'  id='choice_63_51_0'    \/>\n\t\t\t\t<label for='choice_63_51_0' id='label_63_51_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='No'  id='choice_63_51_1'    \/>\n\t\t\t\t<label for='choice_63_51_1' id='label_63_51_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_51_2'>\n\t\t\t\t<input name='input_51' type='radio' value='Decline to answer'  id='choice_63_51_2'    \/>\n\t\t\t\t<label for='choice_63_51_2' id='label_63_51_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_52\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_52\"><label class='gfield_label'  >\u00bfTiene problemas con detectores de humo o mon\u00f3xido de carbono que faltan o no funcionan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_52'>\n\t\t\t<li class='gchoice gchoice_63_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_63_52_0'    \/>\n\t\t\t\t<label for='choice_63_52_0' id='label_63_52_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_63_52_1'    \/>\n\t\t\t\t<label for='choice_63_52_1' id='label_63_52_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_52_2'>\n\t\t\t\t<input name='input_52' type='radio' value='Decline to answer'  id='choice_63_52_2'    \/>\n\t\t\t\t<label for='choice_63_52_2' id='label_63_52_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_53\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_53\"><label class='gfield_label'  >\u00bfLe gustar\u00eda recibir ayuda con su situaci\u00f3n de vida?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_53'>\n\t\t\t<li class='gchoice gchoice_63_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_63_53_0'    \/>\n\t\t\t\t<label for='choice_63_53_0' id='label_63_53_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_63_53_1'    \/>\n\t\t\t\t<label for='choice_63_53_1' id='label_63_53_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_53_2'>\n\t\t\t\t<input name='input_53' type='radio' value='Decline to answer'  id='choice_63_53_2'    \/>\n\t\t\t\t<label for='choice_63_53_2' id='label_63_53_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_54\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_54\"><h2 class=\"gsection_title\">Cuidado de ni\u00f1os<\/h2><\/li><li id=\"field_63_56\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_56\"><label class='gfield_label'  >\u00bfEst\u00e1 actualmente embarazada?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_56'>\n\t\t\t<li class='gchoice gchoice_63_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_63_56_0'    \/>\n\t\t\t\t<label for='choice_63_56_0' id='label_63_56_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_63_56_1'    \/>\n\t\t\t\t<label for='choice_63_56_1' id='label_63_56_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_56_2'>\n\t\t\t\t<input name='input_56' type='radio' value='Decline to answer'  id='choice_63_56_2'    \/>\n\t\t\t\t<label for='choice_63_56_2' id='label_63_56_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_57\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_57\"><label class='gfield_label'  >En los pr\u00f3ximos 12 meses, \u00bfnecesitar\u00e1 ayuda para buscar o pagar el cuidado de ni\u00f1os?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_57'>\n\t\t\t<li class='gchoice gchoice_63_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes'  id='choice_63_57_0'    \/>\n\t\t\t\t<label for='choice_63_57_0' id='label_63_57_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_63_57_1'    \/>\n\t\t\t\t<label for='choice_63_57_1' id='label_63_57_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='Decline to answer'  id='choice_63_57_2'    \/>\n\t\t\t\t<label for='choice_63_57_2' id='label_63_57_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_58\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_58\"><label class='gfield_label'  >\u00bfLe gustar\u00eda recibir ayuda con el cuidado de los ni\u00f1os?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_58'>\n\t\t\t<li class='gchoice gchoice_63_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_63_58_0'    \/>\n\t\t\t\t<label for='choice_63_58_0' id='label_63_58_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_63_58_1'    \/>\n\t\t\t\t<label for='choice_63_58_1' id='label_63_58_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_58_2'>\n\t\t\t\t<input name='input_58' type='radio' value='Decline to answer'  id='choice_63_58_2'    \/>\n\t\t\t\t<label for='choice_63_58_2' id='label_63_58_2'>Prefiero no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_59\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_59\"><em>A continuaci\u00f3n, incluimos algunas preguntas de naturaleza m\u00e1s sensible, que pueden o no aplicarse a usted. Estas preguntas no pretenden ser cr\u00edticas de ninguna manera. Queremos asegurarnos de hacer todo lo posible para evaluar todas sus necesidades, para saber mejor c\u00f3mo ayudarle.<\/em><\/li><li id=\"field_63_60\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_60\"><h2 class=\"gsection_title\">Seguridad<\/h2><div class='gsection_description' id='gfield_description_63_60'>Dado que la violencia y el abuso afectan a muchas personas y comprometen su salud, planteamos las siguientes preguntas. <\/div><\/li><li id=\"field_63_61\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_61\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, le lastima f\u00edsicamente o amenaza con lastimarle?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_61'>\n\t\t\t<li class='gchoice gchoice_63_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Never'  id='choice_63_61_0'    \/>\n\t\t\t\t<label for='choice_63_61_0' id='label_63_61_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Rarely'  id='choice_63_61_1'    \/>\n\t\t\t\t<label for='choice_63_61_1' id='label_63_61_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_61_2'>\n\t\t\t\t<input name='input_61' type='radio' value='Sometimes'  id='choice_63_61_2'    \/>\n\t\t\t\t<label for='choice_63_61_2' id='label_63_61_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_61_3'>\n\t\t\t\t<input name='input_61' type='radio' value='Fairly often'  id='choice_63_61_3'    \/>\n\t\t\t\t<label for='choice_63_61_3' id='label_63_61_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_61_4'>\n\t\t\t\t<input name='input_61' type='radio' value='Frequently'  id='choice_63_61_4'    \/>\n\t\t\t\t<label for='choice_63_61_4' id='label_63_61_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_62\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_62\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia alguien, incluidos familiares y amigos, le reta, grita o insulta?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_62'>\n\t\t\t<li class='gchoice gchoice_63_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Never'  id='choice_63_62_0'    \/>\n\t\t\t\t<label for='choice_63_62_0' id='label_63_62_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Rarely'  id='choice_63_62_1'    \/>\n\t\t\t\t<label for='choice_63_62_1' id='label_63_62_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_62_2'>\n\t\t\t\t<input name='input_62' type='radio' value='Sometimes'  id='choice_63_62_2'    \/>\n\t\t\t\t<label for='choice_63_62_2' id='label_63_62_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_62_3'>\n\t\t\t\t<input name='input_62' type='radio' value='Fairly often'  id='choice_63_62_3'    \/>\n\t\t\t\t<label for='choice_63_62_3' id='label_63_62_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_62_4'>\n\t\t\t\t<input name='input_62' type='radio' value='Frequently'  id='choice_63_62_4'    \/>\n\t\t\t\t<label for='choice_63_62_4' id='label_63_62_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_79\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_79\"><h2 class=\"gsection_title\">Problemas financieros<\/h2><\/li><li id=\"field_63_63\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_63\"><label class='gfield_label'  >Durante los \u00faltimos 3 meses, \u00bfcon qu\u00e9 frecuencia se ha preocupado o angustiado porque sus recursos financieros no alcanzan para cubrir los gastos de su hogar?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_63'>\n\t\t\t<li class='gchoice gchoice_63_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Never'  id='choice_63_63_0'    \/>\n\t\t\t\t<label for='choice_63_63_0' id='label_63_63_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Once or twice but not monthly'  id='choice_63_63_1'    \/>\n\t\t\t\t<label for='choice_63_63_1' id='label_63_63_1'>Una o dos veces, pero no mensualmente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_63_2'>\n\t\t\t\t<input name='input_63' type='radio' value='Monthly'  id='choice_63_63_2'    \/>\n\t\t\t\t<label for='choice_63_63_2' id='label_63_63_2'>Mensualmente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_63_3'>\n\t\t\t\t<input name='input_63' type='radio' value='Weekly'  id='choice_63_63_3'    \/>\n\t\t\t\t<label for='choice_63_63_3' id='label_63_63_3'>Semanalmente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_63_4'>\n\t\t\t\t<input name='input_63' type='radio' value='Daily'  id='choice_63_63_4'    \/>\n\t\t\t\t<label for='choice_63_63_4' id='label_63_63_4'>Diariamente<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_64\"  class=\"gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_63_64\"><label class='gfield_label gfield_label_before_complex'  >\u00bfLe interesar\u00eda recibir informaci\u00f3n o solicitar cualquiera de los siguientes programas que pueden ayudarle a cubrir los gastos m\u00e9dicos y del hogar?<\/label><div class='gfield_description' id='gfield_description_63_64'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_63_64'><li class='gchoice gchoice_63_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Social Security Income (Disability) Benefits'  id='choice_63_64_1'   aria-describedby=\"gfield_description_63_64\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_63_64_1' id='label_63_64_1'>Beneficios de ingresos del Seguro Social (por discapacidad)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_64_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.2' type='checkbox'  value='Medical or Intellectual Disability Medicaid Waiver Programs'  id='choice_63_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_64_2' id='label_63_64_2'>Programas de exenci\u00f3n de Medicaid por discapacidad m\u00e9dica o intelectual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_63_64_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.3' type='checkbox'  value='State Health Services Programs (SNAP, WIC)'  id='choice_63_64_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_63_64_3' id='label_63_64_3'>Programas de servicios de salud del estado (SNAP, WIC)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_65\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_65\"><h2 class=\"gsection_title\">Empleo<\/h2><\/li><li id=\"field_63_66\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_66\"><label class='gfield_label'  >\u00bfDesea recibir ayuda para encontrar o mantener un trabajo o un empleo?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_66'>\n\t\t\t<li class='gchoice gchoice_63_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes, help finding work'  id='choice_63_66_0'    \/>\n\t\t\t\t<label for='choice_63_66_0' id='label_63_66_0'>S\u00ed, para encontrar trabajo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes, help keeping work'  id='choice_63_66_1'    \/>\n\t\t\t\t<label for='choice_63_66_1' id='label_63_66_1'>S\u00ed, para mantener un trabajo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_66_2'>\n\t\t\t\t<input name='input_66' type='radio' value='I do not need or want help'  id='choice_63_66_2'    \/>\n\t\t\t\t<label for='choice_63_66_2' id='label_63_66_2'>No quiero ni necesito ayuda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_67\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_67\"><h2 class=\"gsection_title\">Salud mental<\/h2><\/li><li id=\"field_63_69\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_69\">Durante las \u00faltimas 2 semanas, \u00bfcon qu\u00e9 frecuencia le ha molestado alguno de los siguientes problemas?<\/li><li id=\"field_63_70\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_70\"><label class='gfield_label'  >Poco inter\u00e9s o placer por hacer las cosas<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_70'>\n\t\t\t<li class='gchoice gchoice_63_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='0'  id='choice_63_70_0'    \/>\n\t\t\t\t<label for='choice_63_70_0' id='label_63_70_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='1'  id='choice_63_70_1'    \/>\n\t\t\t\t<label for='choice_63_70_1' id='label_63_70_1'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_70_2'>\n\t\t\t\t<input name='input_70' type='radio' value='2'  id='choice_63_70_2'    \/>\n\t\t\t\t<label for='choice_63_70_2' id='label_63_70_2'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_70_3'>\n\t\t\t\t<input name='input_70' type='radio' value='3'  id='choice_63_70_3'    \/>\n\t\t\t\t<label for='choice_63_70_3' id='label_63_70_3'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_71\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_71\"><label class='gfield_label'  >Sentirse deca\u00edda, deprimida o sin esperanza<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_71'>\n\t\t\t<li class='gchoice gchoice_63_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='0'  id='choice_63_71_0'    \/>\n\t\t\t\t<label for='choice_63_71_0' id='label_63_71_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='1'  id='choice_63_71_1'    \/>\n\t\t\t\t<label for='choice_63_71_1' id='label_63_71_1'>Varios d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_71_2'>\n\t\t\t\t<input name='input_71' type='radio' value='2'  id='choice_63_71_2'    \/>\n\t\t\t\t<label for='choice_63_71_2' id='label_63_71_2'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_71_3'>\n\t\t\t\t<input name='input_71' type='radio' value='3'  id='choice_63_71_3'    \/>\n\t\t\t\t<label for='choice_63_71_3' id='label_63_71_3'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_73\"  class=\"gfield gfield--width-full gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_73\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_73' >PHQ2_Score<\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_63_73' type='text'    value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_63_74\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_74\"><h2 class=\"gsection_title\">Estr\u00e9s<\/h2><div class='gsection_description' id='gfield_description_63_74'>Estr\u00e9s significa una situaci\u00f3n en la que una persona se siente tensa, inquieta, nerviosa o ansiosa, o no puede dormir de noche porque su mente est\u00e1 alterada todo el tiempo.<\/div><\/li><li id=\"field_63_76\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_76\"><label class='gfield_label'  >\u00bfSiente en estos d\u00edas el tipo de estr\u00e9s que acaba de describir?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_76'>\n\t\t\t<li class='gchoice gchoice_63_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Not at all'  id='choice_63_76_0'    \/>\n\t\t\t\t<label for='choice_63_76_0' id='label_63_76_0'>Nada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='A little bit'  id='choice_63_76_1'    \/>\n\t\t\t\t<label for='choice_63_76_1' id='label_63_76_1'>Un poco<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_76_2'>\n\t\t\t\t<input name='input_76' type='radio' value='Somewhat'  id='choice_63_76_2'    \/>\n\t\t\t\t<label for='choice_63_76_2' id='label_63_76_2'>Algo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_76_3'>\n\t\t\t\t<input name='input_76' type='radio' value='Quite a bit'  id='choice_63_76_3'    \/>\n\t\t\t\t<label for='choice_63_76_3' id='label_63_76_3'>Bastante<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_76_4'>\n\t\t\t\t<input name='input_76' type='radio' value='Very much'  id='choice_63_76_4'    \/>\n\t\t\t\t<label for='choice_63_76_4' id='label_63_76_4'>Mucho<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_77\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_77\"><h2 class=\"gsection_title\">Referencias a recursos comunitarios<\/h2><\/li><li id=\"field_63_78\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_63_78\"><label class='gfield_label'  >Despu\u00e9s de completar la evaluaci\u00f3n de NMDoH, \u00bfdesea que el personal de Driscoll Health Plan se comunique con usted para darle referencias comunitarias para necesidades identificadas?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_63_78'>\n\t\t\t<li class='gchoice gchoice_63_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_63_78_0'    \/>\n\t\t\t\t<label for='choice_63_78_0' id='label_63_78_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_63_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_63_78_1'    \/>\n\t\t\t\t<label for='choice_63_78_1' id='label_63_78_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_63_80\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_80\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_80' >Escalate High Risk<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_63_80' type='text' value='Yes' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_81\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_81\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_81' >Escalate Behavioral Health<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_63_81' type='text' value='Yes' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_82\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_82\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_82' >Apply State<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_63_82' type='text' value='Yes' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_83\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_83\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_83' >Apply Med<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_63_83' type='text' value='Yes' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_63_84\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_63_84\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_63_84' >Apply Social<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_63_84' type='text' value='Yes' class='large'      aria-invalid=\"false\"   \/> 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