{"id":561,"date":"2021-08-27T18:12:45","date_gmt":"2021-08-27T18:12:45","guid":{"rendered":"https:\/\/driscoll.gomohealth.care\/?page_id=561"},"modified":"2024-09-04T08:31:15","modified_gmt":"2024-09-04T08:31:15","slug":"prenatalenrollment","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/prenatalenrollment\/","title":{"rendered":"Prenatal Chat Survey"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container 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_60' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_60'  action='\/es\/wp-json\/wp\/v2\/pages\/561' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_60\" \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_60' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_60_32\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_32\"><div class='ginput_container ginput_container_text'><input name='input_32' id='input_60_32' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_60_62\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_62\"><div class='ginput_container ginput_container_text'><input name='input_62' id='input_60_62' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_60_33\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_33\"><div class='ginput_container ginput_container_text'><input name='input_33' id='input_60_33' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/driscoll.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/561' \/><\/div><\/li><li id=\"field_60_63\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_63\"><div class='ginput_container ginput_container_text'><input name='input_63' id='input_60_63' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_60_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_60_1\"><p><b>Por favor responda estas preguntas breves para que podamos conocer sus necesidades y las de su beb\u00e9.<\/b><\/p>\n \n<p><b style=\"color: #790000;\">*<\/b> = requerido<\/p><\/li><li id=\"field_60_64\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_64\"><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_60_64'>\n                            \n                            <span id='input_60_64_3_container' class='name_first' >\n                                                    <input type='text' name='input_64.3' id='input_60_64_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_60_64_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_60_64_6_container' class='name_last' >\n                                                    <input type='text' name='input_64.6' id='input_60_64_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_60_64_6' >Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_60_2\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_2\"><label class='gfield_label' for='input_60_2' >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_2' id='input_60_2' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_60_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_60_2_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_60_2' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_60_65\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_65\"><label class='gfield_label' for='input_60_65' >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 readonly='readonly' name='input_65' id='input_60_65' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_60_113\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_113\"><label class='gfield_label' for='input_60_113' >Medicaid ID:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_113' id='input_60_113' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_60_115\"  class=\"gfield gfield--width-full copy-115-to-113 gwcopy gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_60_115\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_60_115' >Medicaid ID:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_60_115' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_60_114\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_114\"><label class='gfield_label' for='input_60_114' >Medicaid ID:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_60_114' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_60_111\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_111\"><label class='gfield_label'  >\u00bfSabe cu\u00e1l es su fecha de parto?<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_60_111'>\n\t\t\t<li class='gchoice gchoice_60_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Yes'  id='choice_60_111_0'    \/>\n\t\t\t\t<label for='choice_60_111_0' id='label_60_111_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='No'  id='choice_60_111_1'    \/>\n\t\t\t\t<label for='choice_60_111_1' id='label_60_111_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_112\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_112\"><label class='gfield_label' for='input_60_112' >Indique su fecha de parto:<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_112' id='input_60_112' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_60_112_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_60_112_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_60_112' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_60_36\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_36\"><label class='gfield_label'  >\u00bfCu\u00e1nto tiempo de embarazo tiene?<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_60_36'>\n\t\t\t<li class='gchoice gchoice_60_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='1-2 months'  id='choice_60_36_0'    \/>\n\t\t\t\t<label for='choice_60_36_0' id='label_60_36_0'>1-2 meses<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='3-4 months'  id='choice_60_36_1'    \/>\n\t\t\t\t<label for='choice_60_36_1' id='label_60_36_1'>3-4 meses<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='5-6 months'  id='choice_60_36_2'    \/>\n\t\t\t\t<label for='choice_60_36_2' id='label_60_36_2'>5-6 meses<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_36_3'>\n\t\t\t\t<input name='input_36' type='radio' value='7-8 months'  id='choice_60_36_3'    \/>\n\t\t\t\t<label for='choice_60_36_3' id='label_60_36_3'>7-8 meses<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_36_4'>\n\t\t\t\t<input name='input_36' type='radio' value='Due any minute now'  id='choice_60_36_4'    \/>\n\t\t\t\t<label for='choice_60_36_4' id='label_60_36_4'>Nace en cualquier momento<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_36_5'>\n\t\t\t\t<input name='input_36' type='radio' value='Not sure'  id='choice_60_36_5'    \/>\n\t\t\t\t<label for='choice_60_36_5' id='label_60_36_5'>No estoy seguro<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_37\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_37\"><label class='gfield_label'  >\u00bfTiene alguna inquietud sobre su salud o la de su beb\u00e9?<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_60_37'>\n\t\t\t<li class='gchoice gchoice_60_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Yes'  id='choice_60_37_0'    \/>\n\t\t\t\t<label for='choice_60_37_0' id='label_60_37_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_60_37_1'    \/>\n\t\t\t\t<label for='choice_60_37_1' id='label_60_37_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_72\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_72\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Estas preguntas nos permitir\u00e1n saber c\u00f3mo podemos ayudarle. Tambi\u00e9n recibir\u00e1 una tarjeta de regalo de $20 por completar esta secci\u00f3n. Una de nuestras enfermeras se comunicar\u00e1 con usted para obtener m\u00e1s ayuda.<\/h3><\/li><li id=\"field_60_73\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_73\"><label class='gfield_label'  >Si este no es su primer embarazo, \u00bftuvo problemas con sus otros embarazos?<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_60_73'>\n\t\t\t<li class='gchoice gchoice_60_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_60_73_0'    \/>\n\t\t\t\t<label for='choice_60_73_0' id='label_60_73_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_60_73_1'    \/>\n\t\t\t\t<label for='choice_60_73_1' id='label_60_73_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_73_2'>\n\t\t\t\t<input name='input_73' type='radio' value='Not applicable'  id='choice_60_73_2'    \/>\n\t\t\t\t<label for='choice_60_73_2' id='label_60_73_2'>No aplicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_75\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_75\"><label class='gfield_label' for='input_60_75' >Por favor, enumere las problemas:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_60_75' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_60_76\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_76\"><label class='gfield_label gfield_label_before_complex'  >\u00bfTiene usted alguno de los siguientes problemas de salud?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_76'><li class='gchoice gchoice_60_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Diabetes'  id='choice_60_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_76_1' id='label_60_76_1'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Depression'  id='choice_60_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_76_2' id='label_60_76_2'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='Heart Disease'  id='choice_60_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_76_3' id='label_60_76_3'>Enfermedad card\u00edaca<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_76_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.4' type='checkbox'  value='Kidney Disease'  id='choice_60_76_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_76_4' id='label_60_76_4'>Enfermedad renal<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_77\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_77\"><label class='gfield_label'  >\u00bfFuma?<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_60_77'>\n\t\t\t<li class='gchoice gchoice_60_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Yes'  id='choice_60_77_0'    \/>\n\t\t\t\t<label for='choice_60_77_0' id='label_60_77_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='No'  id='choice_60_77_1'    \/>\n\t\t\t\t<label for='choice_60_77_1' id='label_60_77_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_79\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_79\"><label class='gfield_label'  >\u00bfDesea que nuestros trabajadores sociales le ayuden con alguna necesidad?<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_60_79'>\n\t\t\t<li class='gchoice gchoice_60_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_60_79_0'    \/>\n\t\t\t\t<label for='choice_60_79_0' id='label_60_79_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_60_79_1'    \/>\n\t\t\t\t<label for='choice_60_79_1' id='label_60_79_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_80\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_80\"><label class='gfield_label' for='input_60_80' >Indique las necesidades con las cuales necesita ayuda.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_60_80' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_60_98\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_98\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\"><\/h3><\/li><li id=\"field_60_39\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_39\"><label class='gfield_label'  >\u00bf Ha consultado a su m\u00e9dico obstetra\/ginec\u00f3logo?<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_60_39'>\n\t\t\t<li class='gchoice gchoice_60_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_60_39_0'    \/>\n\t\t\t\t<label for='choice_60_39_0' id='label_60_39_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_60_39_1'    \/>\n\t\t\t\t<label for='choice_60_39_1' id='label_60_39_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_68\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_68\"><label class='gfield_label'  >\u00bfTiene otros hijos en Driscoll Health Plan?<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_60_68'>\n\t\t\t<li class='gchoice gchoice_60_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_60_68_0'    \/>\n\t\t\t\t<label for='choice_60_68_0' id='label_60_68_0'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_60_68_1'    \/>\n\t\t\t\t<label for='choice_60_68_1' id='label_60_68_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_69\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_60_69\"><label class='gfield_label gfield_label_before_complex'  >\u00bfPor qu\u00e9 eligi\u00f3 Driscoll Health Plan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_60_69'>Seleccione todas las opciones que correspondan<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_69'><li class='gchoice gchoice_60_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Because of the extra benefits (Value Added Services)'  id='choice_60_69_1'   aria-describedby=\"gfield_description_60_69\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_1' id='label_60_69_1'>Debido a los beneficios adicionales (Servicios de Valor Agregado)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Because my doctor(s) take Driscoll Health Plan'  id='choice_60_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_2' id='label_60_69_2'>Porque mi (s) m\u00e9dico (s) aceptan Driscoll Health Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='Because my kids have Driscoll Health Plan'  id='choice_60_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_3' id='label_60_69_3'>Porque mis hijos tienen Driscoll Health Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_69_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.4' type='checkbox'  value='Because friends\/family recommended Driscoll Health Plan'  id='choice_60_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_4' id='label_60_69_4'>Porque los amigos\/familiares recomendaron Driscoll Health Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_69_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.5' type='checkbox'  value='Because I saw an advertisement in the community'  id='choice_60_69_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_5' id='label_60_69_5'>Porque vi un anuncio en la comunidad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_60_69_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.6' type='checkbox'  value='Other'  id='choice_60_69_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_69_6' id='label_60_69_6'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_71\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_71\"><label class='gfield_label' for='input_60_71' >Se ha seleccionado &quot;Otro&quot;, especifique:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_60_71' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_60_67\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_67\"><label class='gfield_label'  >\u00bfCu\u00e1l es su m\u00e9todo de contacto preferido?<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_60_67'>\n\t\t\t<li class='gchoice gchoice_60_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Text'  id='choice_60_67_0'    \/>\n\t\t\t\t<label for='choice_60_67_0' id='label_60_67_0'>Mensaje de texto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='Email'  id='choice_60_67_1'    \/>\n\t\t\t\t<label for='choice_60_67_1' id='label_60_67_1'>Correo electr\u00f3nico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_60_67_2'>\n\t\t\t\t<input name='input_67' type='radio' value='Phone call'  id='choice_60_67_2'    \/>\n\t\t\t\t<label for='choice_60_67_2' id='label_60_67_2'>Llamada telef\u00f3nica<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_60_66\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_66\"><label class='gfield_label' for='input_60_66' >\u00bfCu\u00e1l es su direcci\u00f3n de correo electr\u00f3nico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_66' id='input_60_66' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_60_59\"  class=\"gfield mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_59\"><label class='gfield_label' for='input_60_59' >Comentarios adicionales:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_60_59' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_60_34\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_60_34\"><div class='ginput_container ginput_container_text'><input name='input_34' id='input_60_34' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_60_99\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_60_99\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_60_99' >SendEscalation<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_60_99' type='text' value='Yes' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_60_102\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_60_102\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_60_102' >PriorProblems<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_60_102' type='text' value='Problems with prior pregnancy&lt;br&gt;' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li 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