{"id":26,"date":"2019-04-16T16:44:12","date_gmt":"2019-04-16T16:44:12","guid":{"rendered":"http:\/\/driscoll.gomohealth.care\/adult-hra\/"},"modified":"2023-11-20T15:54:34","modified_gmt":"2023-11-20T15:54:34","slug":"adult-hra","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/adult-hra\/","title":{"rendered":"Adult 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_56' style='display:none'><div id='gf_56' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_56' id='gform_56'  action='\/es\/wp-json\/wp\/v2\/pages\/26#gf_56' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_56\" \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_56' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_56_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_56_1\"><p>Bienvenido al Driscoll Health Plan. Responda las pr\u00f3ximas preguntas de la Evaluaci\u00f3n de riesgos de salud 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_56_2\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_56_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_56_2'>\n                            \n                            <span id='input_56_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_56_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_56_2_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_56_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_56_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_56_2_6' >Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_56_25\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_25\"><label class='gfield_label' for='input_56_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_56_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_26\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_26\"><label class='gfield_label' for='input_56_26' >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_26' id='input_56_26' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_56_26_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_56_26_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_56_26' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_56_27\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_27\"><label class='gfield_label' for='input_56_27' >Edad:<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_56_27' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_28\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_28\"><label class='gfield_label gfield_label_before_complex'  >Direcci\u00f3n del miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_56_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_56_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_56_28_1' value=''    aria-required='true'    \/>\n                                        <label for='input_56_28_1' id='input_56_28_1_label' >Direcci\u00f3n del miembro:<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_56_28_2_container' >\n                                        <input type='text' name='input_28.2' id='input_56_28_2' value=''     aria-required='false'   \/>\n                                        <label for='input_56_28_2' id='input_56_28_2_label' >Direcci\u00f3n del miembro 2:<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_56_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_56_28_3' value=''    aria-required='true'    \/>\n                                    <label for='input_56_28_3' id='input_56_28_3_label' >Ciudad del miembro:<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_56_28_4_container' >\n                                        <select name='input_28.4' id='input_56_28_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_56_28_4' id='input_56_28_4_label' >Estado del miembro:<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_56_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_56_28_5' value=''    aria-required='true'    \/>\n                                    <label for='input_56_28_5' id='input_56_28_5_label' >C\u00f3digo postal del miembro:<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_56_28_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_56_29\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_29\"><label class='gfield_label' for='input_56_29' >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_29' id='input_56_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_10\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_10\"><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_56_10'>\n\t\t\t<li class='gchoice gchoice_56_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Excellent'  id='choice_56_10_0'    \/>\n\t\t\t\t<label for='choice_56_10_0' id='label_56_10_0'>Excelente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Good'  id='choice_56_10_1'    \/>\n\t\t\t\t<label for='choice_56_10_1' id='label_56_10_1'>Bueno<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='Poor'  id='choice_56_10_2'    \/>\n\t\t\t\t<label for='choice_56_10_2' id='label_56_10_2'>Pobre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='Very Poor'  id='choice_56_10_3'    \/>\n\t\t\t\t<label for='choice_56_10_3' id='label_56_10_3'>Muy pobre<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_31\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_31\"><label class='gfield_label' for='input_56_31' >Anote a continuaci\u00f3n las condiciones:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_56_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_56_4\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_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_56_4'>\n\t\t\t<li class='gchoice gchoice_56_4_0'>\n\t\t\t\t<input name='input_4' type='radio' value='Yes'  id='choice_56_4_0'    \/>\n\t\t\t\t<label for='choice_56_4_0' id='label_56_4_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_4_1'>\n\t\t\t\t<input name='input_4' type='radio' value='No'  id='choice_56_4_1'    \/>\n\t\t\t\t<label for='choice_56_4_1' id='label_56_4_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_30\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_30\"><label class='gfield_label' for='input_56_30' >\u00bfQu\u00e9 equipo?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_56_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_3\"  class=\"gfield gfield--width-full mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_3\"><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_56_3'>\n\t\t\t<li class='gchoice gchoice_56_3_0'>\n\t\t\t\t<input name='input_3' type='radio' value='Yes'  id='choice_56_3_0'    \/>\n\t\t\t\t<label for='choice_56_3_0' id='label_56_3_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_3_1'>\n\t\t\t\t<input name='input_3' type='radio' value='No'  id='choice_56_3_1'    \/>\n\t\t\t\t<label for='choice_56_3_1' id='label_56_3_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_32\"><label class='gfield_label' for='input_56_32' >\u00bfAd\u00f3nde viaja?<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_56_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_33\"  class=\"gfield gfield--width-full mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_33\"><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_56_33'>\n\t\t\t<li class='gchoice gchoice_56_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_56_33_0'    \/>\n\t\t\t\t<label for='choice_56_33_0' id='label_56_33_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_56_33_1'    \/>\n\t\t\t\t<label for='choice_56_33_1' id='label_56_33_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_34\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_34\"><label class='gfield_label' for='input_56_34' >Indique a continuaci\u00f3n las condiciones:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_56_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_56_35\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_35\"><label class='gfield_label gfield_label_before_complex'  >\u00bfTiene el miembro alguno de estos problemas de salud?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_56_35'><li class='gchoice gchoice_56_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Heart'  id='choice_56_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_1' id='label_56_35_1'>Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Cancer'  id='choice_56_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_2' id='label_56_35_2'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Bleeding'  id='choice_56_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_3' id='label_56_35_3'>Sangrado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Diabetes'  id='choice_56_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_4' id='label_56_35_4'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Kidney'  id='choice_56_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_5' id='label_56_35_5'>Ri\u00f1\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.6' type='checkbox'  value='COPD'  id='choice_56_35_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_6' id='label_56_35_6'>COPD\/EPOC<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.7' type='checkbox'  value='Cystic Fibrosis'  id='choice_56_35_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_7' id='label_56_35_7'>Fibrosis qu\u00edstica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.8' type='checkbox'  value='HIV\/AIDS'  id='choice_56_35_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_8' id='label_56_35_8'>HIV\/AIDS<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.9' type='checkbox'  value='Mental Health'  id='choice_56_35_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_9' id='label_56_35_9'>Salud mental<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.11' type='checkbox'  value='Depression'  id='choice_56_35_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_11' id='label_56_35_11'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.12' type='checkbox'  value='Eating Disorders'  id='choice_56_35_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_12' id='label_56_35_12'>Trastornos de la alimentaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_56_35_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.13' type='checkbox'  value='Substance Misuse'  id='choice_56_35_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_35_13' id='label_56_35_13'>Abuso de sustancias<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_36\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_36\"><label class='gfield_label' for='input_56_36' >Indique si tiene otros problemas:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_56_36' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_56_44\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_44\"><label class='gfield_label'  >\u00bfTiene enc\u00edas inflamadas o sangrantes, dolor de muelas, problemas para comer o masticar alimentos u otros problemas en tu boca?<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_56_44'>\n\t\t\t<li class='gchoice gchoice_56_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Yes'  id='choice_56_44_0'    \/>\n\t\t\t\t<label for='choice_56_44_0' id='label_56_44_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='No'  id='choice_56_44_1'    \/>\n\t\t\t\t<label for='choice_56_44_1' id='label_56_44_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_5\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_5\"><label class='gfield_label'  >\u00bfHa hecho el miembro 3 visitas a la sala de emergencias o 1 admisi\u00f3n por diabetes en los \u00faltimos 90 d\u00edas?<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_56_5'>\n\t\t\t<li class='gchoice gchoice_56_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Yes'  id='choice_56_5_0'    \/>\n\t\t\t\t<label for='choice_56_5_0' id='label_56_5_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='No'  id='choice_56_5_1'    \/>\n\t\t\t\t<label for='choice_56_5_1' id='label_56_5_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_6\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_6\"><label class='gfield_label'  >\u00bfHa hecho el miembro 3 visitas a la sala de emergencias o 1 admisi\u00f3n por asma en los \u00faltimos 90 d\u00edas?<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_56_6'>\n\t\t\t<li class='gchoice gchoice_56_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Yes'  id='choice_56_6_0'    \/>\n\t\t\t\t<label for='choice_56_6_0' id='label_56_6_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='No'  id='choice_56_6_1'    \/>\n\t\t\t\t<label for='choice_56_6_1' id='label_56_6_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_37\"  class=\"gfield gfield--width-full mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_37\"><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_56_37'>\n\t\t\t<li class='gchoice gchoice_56_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Yes'  id='choice_56_37_0'    \/>\n\t\t\t\t<label for='choice_56_37_0' id='label_56_37_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_56_37_1'    \/>\n\t\t\t\t<label for='choice_56_37_1' id='label_56_37_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_38\"  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_56_38\"><h3 style=\"font-weight: bold; font-size: 20px; margin-top:35px; border-bottom: 1px solid #ddd; padding-bottom: 10px;\">Condiciones de vivienda<\/h3><\/li><li id=\"field_56_14\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_14\"><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_56_14'>\n\t\t\t<li class='gchoice gchoice_56_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Rent'  id='choice_56_14_0'    \/>\n\t\t\t\t<label for='choice_56_14_0' id='label_56_14_0'>Alquila<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Own'  id='choice_56_14_1'    \/>\n\t\t\t\t<label for='choice_56_14_1' id='label_56_14_1'>Due\u00f1o\/a<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Live with a relative\/friend'  id='choice_56_14_2'    \/>\n\t\t\t\t<label for='choice_56_14_2' id='label_56_14_2'>Vive con pariente\/amigo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_15\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_15\"><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_56_15'>\n\t\t\t<li class='gchoice gchoice_56_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_56_15_0'    \/>\n\t\t\t\t<label for='choice_56_15_0' id='label_56_15_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_56_15_1'    \/>\n\t\t\t\t<label for='choice_56_15_1' id='label_56_15_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_16\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_16\"><label class='gfield_label' for='input_56_16' >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_16' id='input_56_16' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_56_39\"  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_56_39\"><h3 style=\"font-weight: bold; font-size: 20px; margin-top:35px; border-bottom: 1px solid #ddd; padding-bottom: 10px;\">Comida<\/h3><\/li><li id=\"field_56_17\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_17\"><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_56_17'>\n\t\t\t<li class='gchoice gchoice_56_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Often true'  id='choice_56_17_0'    \/>\n\t\t\t\t<label for='choice_56_17_0' id='label_56_17_0'>A menudo es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Sometimes true'  id='choice_56_17_1'    \/>\n\t\t\t\t<label for='choice_56_17_1' id='label_56_17_1'>A veces es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='Never true'  id='choice_56_17_2'    \/>\n\t\t\t\t<label for='choice_56_17_2' id='label_56_17_2'>Nunca es cierto<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_18\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_18\"><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_56_18'>\n\t\t\t<li class='gchoice gchoice_56_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Often true'  id='choice_56_18_0'    \/>\n\t\t\t\t<label for='choice_56_18_0' id='label_56_18_0'>A menudo es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Sometimes true'  id='choice_56_18_1'    \/>\n\t\t\t\t<label for='choice_56_18_1' id='label_56_18_1'>A veces es cierto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='Never true'  id='choice_56_18_2'    \/>\n\t\t\t\t<label for='choice_56_18_2' id='label_56_18_2'>Nunca es cierto<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_40\"  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_56_40\"><h3 style=\"font-weight: bold; font-size: 20px; margin-top:35px; border-bottom: 1px solid #ddd; padding-bottom: 10px;\">Servicios de transporte<\/h3><\/li><li id=\"field_56_19\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_19\"><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_56_19'>\n\t\t\t<li class='gchoice gchoice_56_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_56_19_0'    \/>\n\t\t\t\t<label for='choice_56_19_0' id='label_56_19_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_56_19_1'    \/>\n\t\t\t\t<label for='choice_56_19_1' id='label_56_19_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_41\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_41\"><label class='gfield_label' for='input_56_41' >Indique por favor:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_56_41' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_56_42\"  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_56_42\"><h3 style=\"font-weight: bold; font-size: 20px; margin-top:35px; border-bottom: 1px solid #ddd; padding-bottom: 10px;\">Servicios p\u00fablicos<\/h3><\/li><li id=\"field_56_20\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_20\"><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_56_20'>\n\t\t\t<li class='gchoice gchoice_56_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_56_20_0'    \/>\n\t\t\t\t<label for='choice_56_20_0' id='label_56_20_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_56_20_1'    \/>\n\t\t\t\t<label for='choice_56_20_1' id='label_56_20_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='Already shut off'  id='choice_56_20_2'    \/>\n\t\t\t\t<label for='choice_56_20_2' id='label_56_20_2'>Ya est\u00e1 apagado<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_43\"  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_56_43\"><h3 style=\"font-weight: bold; font-size: 20px; margin-top:35px; border-bottom: 1px solid #ddd; padding-bottom: 10px;\">Seguridad<\/h3><\/li><li id=\"field_56_21\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_21\"><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_56_21'>\n\t\t\t<li class='gchoice gchoice_56_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Never'  id='choice_56_21_0'    \/>\n\t\t\t\t<label for='choice_56_21_0' id='label_56_21_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Rarely'  id='choice_56_21_1'    \/>\n\t\t\t\t<label for='choice_56_21_1' id='label_56_21_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='Sometimes'  id='choice_56_21_2'    \/>\n\t\t\t\t<label for='choice_56_21_2' id='label_56_21_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='Fairly often'  id='choice_56_21_3'    \/>\n\t\t\t\t<label for='choice_56_21_3' id='label_56_21_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_21_4'>\n\t\t\t\t<input name='input_21' type='radio' value='Frequently'  id='choice_56_21_4'    \/>\n\t\t\t\t<label for='choice_56_21_4' id='label_56_21_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_22\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_22\"><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_56_22'>\n\t\t\t<li class='gchoice gchoice_56_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Never'  id='choice_56_22_0'    \/>\n\t\t\t\t<label for='choice_56_22_0' id='label_56_22_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Rarely'  id='choice_56_22_1'    \/>\n\t\t\t\t<label for='choice_56_22_1' id='label_56_22_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Sometimes'  id='choice_56_22_2'    \/>\n\t\t\t\t<label for='choice_56_22_2' id='label_56_22_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='Fairly often'  id='choice_56_22_3'    \/>\n\t\t\t\t<label for='choice_56_22_3' id='label_56_22_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_22_4'>\n\t\t\t\t<input name='input_22' type='radio' value='Frequently'  id='choice_56_22_4'    \/>\n\t\t\t\t<label for='choice_56_22_4' id='label_56_22_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_23\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_23\"><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_56_23'>\n\t\t\t<li class='gchoice gchoice_56_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Never'  id='choice_56_23_0'    \/>\n\t\t\t\t<label for='choice_56_23_0' id='label_56_23_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Rarely'  id='choice_56_23_1'    \/>\n\t\t\t\t<label for='choice_56_23_1' id='label_56_23_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='Sometimes'  id='choice_56_23_2'    \/>\n\t\t\t\t<label for='choice_56_23_2' id='label_56_23_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_23_3'>\n\t\t\t\t<input name='input_23' type='radio' value='Fairly often'  id='choice_56_23_3'    \/>\n\t\t\t\t<label for='choice_56_23_3' id='label_56_23_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_23_4'>\n\t\t\t\t<input name='input_23' type='radio' value='Frequently'  id='choice_56_23_4'    \/>\n\t\t\t\t<label for='choice_56_23_4' id='label_56_23_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_24\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_24\"><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_56_24'>\n\t\t\t<li class='gchoice gchoice_56_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Never'  id='choice_56_24_0'    \/>\n\t\t\t\t<label for='choice_56_24_0' id='label_56_24_0'>No, nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='Rarely'  id='choice_56_24_1'    \/>\n\t\t\t\t<label for='choice_56_24_1' id='label_56_24_1'>Rara vez<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_24_2'>\n\t\t\t\t<input name='input_24' type='radio' value='Sometimes'  id='choice_56_24_2'    \/>\n\t\t\t\t<label for='choice_56_24_2' id='label_56_24_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_24_3'>\n\t\t\t\t<input name='input_24' type='radio' value='Fairly often'  id='choice_56_24_3'    \/>\n\t\t\t\t<label for='choice_56_24_3' id='label_56_24_3'>Bastante a menudo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_56_24_4'>\n\t\t\t\t<input name='input_24' type='radio' value='Frequently'  id='choice_56_24_4'    \/>\n\t\t\t\t<label for='choice_56_24_4' id='label_56_24_4'>Con frecuencia<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_56_11\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_56_11\"><div class='ginput_container ginput_container_text'><input name='input_11' id='input_56_11' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='English' \/><\/div><\/li><li id=\"field_56_12\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_56_12\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_56_12' >subsid<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_56_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_56_13\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_56_13\"><div class='admin-hidden-markup'><i class='gform-icon 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\/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"129\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_56' id='gform_ajax_frame_56' title='Este iframe contiene la l\u00f3gica necesaria para gestionar formularios con ajax activado.'><\/iframe>\n                <script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 56, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_56').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_56');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_56').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_56').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_56').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_56').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_56').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_56').val();gformInitSpinner( 56, '\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [56, current_page]);window['gf_submitting_56'] = 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_56').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_56').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [56]);window['gf_submitting_56'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_56').text());}, 50);}else{jQuery('#gform_56').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [56, 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-002 9\/23<br \/>\n<\/span><span data-contrast=\"auto\">Center for Disease Control and Prevention, (2011) 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 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