{"id":619,"date":"2021-12-23T17:26:35","date_gmt":"2021-12-23T17:26:35","guid":{"rendered":"https:\/\/driscoll.gomohealth.care\/prenatal-health-concerns-survey\/"},"modified":"2021-12-23T17:33:04","modified_gmt":"2021-12-23T17:33:04","slug":"prenatalconcerns","status":"publish","type":"page","link":"https:\/\/driscoll.gomohealth.care\/es\/prenatalconcerns\/","title":{"rendered":"Prenatal Health Concerns 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;\"><div class=\"fusion-text fusion-text-1\"><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_37' style='display:none'><div id='gf_37' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_37' id='gform_37'  action='\/es\/wp-json\/wp\/v2\/pages\/619#gf_37' ><input type=\"hidden\" value=\"0\" name=\"gpps_page_progression_37\" \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_37' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_37_32\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_32\"><div class='ginput_container ginput_container_text'><input name='input_32' id='input_37_32' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_37_62\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_62\"><div class='ginput_container ginput_container_text'><input name='input_62' id='input_37_62' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_37_33\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_33\"><div class='ginput_container ginput_container_text'><input name='input_33' id='input_37_33' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/driscoll.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/619' \/><\/div><\/li><li id=\"field_37_63\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_63\"><div class='ginput_container ginput_container_text'><input name='input_63' id='input_37_63' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_37_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_37_1\"><p><b>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.<\/b><\/p>\n \n<p><b style=\"color: #790000;\">*<\/b> = requerido<\/p><\/li><li id=\"field_37_64\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_64'>\n                            \n                            <span id='input_37_64_3_container' class='name_first' >\n                                                    <input type='text' name='input_64.3' id='input_37_64_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_64_3' >Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_37_64_6_container' class='name_last' >\n                                                    <input type='text' name='input_64.6' id='input_37_64_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_64_6' >Apellido<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_37_2\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_2\"><label class='gfield_label' for='input_37_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_37_2' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_37_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_37_2_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_37_2' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_37_65\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_65\"><label class='gfield_label' for='input_37_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 name='input_65' id='input_37_65' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_37_73\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_73'>\n\t\t\t<li class='gchoice gchoice_37_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_37_73_0'    \/>\n\t\t\t\t<label for='choice_37_73_0' id='label_37_73_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_37_73_1'    \/>\n\t\t\t\t<label for='choice_37_73_1' id='label_37_73_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_73_2'>\n\t\t\t\t<input name='input_73' type='radio' value='Not applicable'  id='choice_37_73_2'    \/>\n\t\t\t\t<label for='choice_37_73_2' id='label_37_73_2'>No aplicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_75\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_75\"><label class='gfield_label' for='input_37_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_37_75' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_37_76\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_76'><li class='gchoice gchoice_37_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_37_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_76_1' id='label_37_76_1'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_76_2' id='label_37_76_2'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_76_3' id='label_37_76_3'>Enfermedad card\u00edaca<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_76_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_76_4' id='label_37_76_4'>Enfermedad renal<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_77\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_77'>\n\t\t\t<li class='gchoice gchoice_37_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Yes'  id='choice_37_77_0'    \/>\n\t\t\t\t<label for='choice_37_77_0' id='label_37_77_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='No'  id='choice_37_77_1'    \/>\n\t\t\t\t<label for='choice_37_77_1' id='label_37_77_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_79\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_79'>\n\t\t\t<li class='gchoice gchoice_37_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_37_79_0'    \/>\n\t\t\t\t<label for='choice_37_79_0' id='label_37_79_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_37_79_1'    \/>\n\t\t\t\t<label for='choice_37_79_1' id='label_37_79_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_80\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_80\"><label class='gfield_label' for='input_37_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_37_80' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_37_81\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_81\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Condiciones de vivienda<\/h3><\/li><li id=\"field_37_82\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_82\"><label class='gfield_label'  >\u00bfCu\u00e1l es hoy su condici\u00f3n de vivienda?<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_37_82'>\n\t\t\t<li class='gchoice gchoice_37_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Rent'  id='choice_37_82_0'    \/>\n\t\t\t\t<label for='choice_37_82_0' id='label_37_82_0'>Alquila<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='Own'  id='choice_37_82_1'    \/>\n\t\t\t\t<label for='choice_37_82_1' id='label_37_82_1'>Propietario<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_82_2'>\n\t\t\t\t<input name='input_82' type='radio' value='Live with a relative\/friend'  id='choice_37_82_2'    \/>\n\t\t\t\t<label for='choice_37_82_2' id='label_37_82_2'>Vive con un familiar o amigo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_83\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_83\"><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_37_83'>\n\t\t\t<li class='gchoice gchoice_37_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Yes'  id='choice_37_83_0'    \/>\n\t\t\t\t<label for='choice_37_83_0' id='label_37_83_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='No'  id='choice_37_83_1'    \/>\n\t\t\t\t<label for='choice_37_83_1' id='label_37_83_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_84\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_84\"><label class='gfield_label' for='input_37_84' >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_84' id='input_37_84' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_37_85\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_85\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Comida<\/h3><\/li><li id=\"field_37_89\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_89\"><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?<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_37_89'>\n\t\t\t<li class='gchoice gchoice_37_89_0'>\n\t\t\t\t<input name='input_89' type='radio' value='Often true'  id='choice_37_89_0'    \/>\n\t\t\t\t<label for='choice_37_89_0' id='label_37_89_0'>Casi siempre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_89_1'>\n\t\t\t\t<input name='input_89' type='radio' value='Sometimes true'  id='choice_37_89_1'    \/>\n\t\t\t\t<label for='choice_37_89_1' id='label_37_89_1'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_89_2'>\n\t\t\t\t<input name='input_89' type='radio' value='Never true'  id='choice_37_89_2'    \/>\n\t\t\t\t<label for='choice_37_89_2' id='label_37_89_2'>Nunca<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_90\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_90\"><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?<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_37_90'>\n\t\t\t<li class='gchoice gchoice_37_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Often true'  id='choice_37_90_0'    \/>\n\t\t\t\t<label for='choice_37_90_0' id='label_37_90_0'>Casi siempre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='Sometimes true'  id='choice_37_90_1'    \/>\n\t\t\t\t<label for='choice_37_90_1' id='label_37_90_1'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_90_2'>\n\t\t\t\t<input name='input_90' type='radio' value='Never true'  id='choice_37_90_2'    \/>\n\t\t\t\t<label for='choice_37_90_2' id='label_37_90_2'>Nunca<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_86\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_86\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Servicios de transporte<\/h3><\/li><li id=\"field_37_91\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_91\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfla falta de transporte confiable le impidi\u00f3 asistir a citas m\u00e9dicas o reuniones, trabajar u obtener 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_37_91'>\n\t\t\t<li class='gchoice gchoice_37_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='Yes'  id='choice_37_91_0'    \/>\n\t\t\t\t<label for='choice_37_91_0' id='label_37_91_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='No'  id='choice_37_91_1'    \/>\n\t\t\t\t<label for='choice_37_91_1' id='label_37_91_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_92\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_92\"><label class='gfield_label' for='input_37_92' >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_92' id='input_37_92' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_37_87\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_87\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Servicios p\u00fablicos<\/h3><\/li><li id=\"field_37_93\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_93\"><label class='gfield_label'  >En los \u00faltimos 12 meses, \u00bfuna compa\u00f1\u00eda de electricidad, gas, petr\u00f3leo o agua ha amenazado con interrumpir 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_37_93'>\n\t\t\t<li class='gchoice gchoice_37_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_37_93_0'    \/>\n\t\t\t\t<label for='choice_37_93_0' id='label_37_93_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_37_93_1'    \/>\n\t\t\t\t<label for='choice_37_93_1' id='label_37_93_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_93_2'>\n\t\t\t\t<input name='input_93' type='radio' value='Already Shut Off'  id='choice_37_93_2'    \/>\n\t\t\t\t<label for='choice_37_93_2' id='label_37_93_2'>Ya fueron interrumpido<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_88\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_88\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\">Seguridad<\/h3><\/li><li id=\"field_37_94\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_94\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia una persona, incluidos sus familiares y amigos, le 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_37_94'>\n\t\t\t<li class='gchoice gchoice_37_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Never'  id='choice_37_94_0'    \/>\n\t\t\t\t<label for='choice_37_94_0' id='label_37_94_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Rarely'  id='choice_37_94_1'    \/>\n\t\t\t\t<label for='choice_37_94_1' id='label_37_94_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_94_2'>\n\t\t\t\t<input name='input_94' type='radio' value='Sometimes'  id='choice_37_94_2'    \/>\n\t\t\t\t<label for='choice_37_94_2' id='label_37_94_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_94_3'>\n\t\t\t\t<input name='input_94' type='radio' value='Fairly Often'  id='choice_37_94_3'    \/>\n\t\t\t\t<label for='choice_37_94_3' id='label_37_94_3'>Bastante seguido<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_94_4'>\n\t\t\t\t<input name='input_94' type='radio' value='Frequently'  id='choice_37_94_4'    \/>\n\t\t\t\t<label for='choice_37_94_4' id='label_37_94_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_95\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_95\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia una persona, incluidos sus familiares y amigos, le insulta o le habla con desprecio?<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_37_95'>\n\t\t\t<li class='gchoice gchoice_37_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Never'  id='choice_37_95_0'    \/>\n\t\t\t\t<label for='choice_37_95_0' id='label_37_95_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Rarely'  id='choice_37_95_1'    \/>\n\t\t\t\t<label for='choice_37_95_1' id='label_37_95_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_95_2'>\n\t\t\t\t<input name='input_95' type='radio' value='Sometimes'  id='choice_37_95_2'    \/>\n\t\t\t\t<label for='choice_37_95_2' id='label_37_95_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_95_3'>\n\t\t\t\t<input name='input_95' type='radio' value='Fairly Often'  id='choice_37_95_3'    \/>\n\t\t\t\t<label for='choice_37_95_3' id='label_37_95_3'>Bastante seguido<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_95_4'>\n\t\t\t\t<input name='input_95' type='radio' value='Frequently'  id='choice_37_95_4'    \/>\n\t\t\t\t<label for='choice_37_95_4' id='label_37_95_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_96\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_96\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia una persona, incluidos sus familiares y amigos, le amenaza con lastimarle 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_37_96'>\n\t\t\t<li class='gchoice gchoice_37_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Never'  id='choice_37_96_0'    \/>\n\t\t\t\t<label for='choice_37_96_0' id='label_37_96_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='Rarely'  id='choice_37_96_1'    \/>\n\t\t\t\t<label for='choice_37_96_1' id='label_37_96_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_96_2'>\n\t\t\t\t<input name='input_96' type='radio' value='Sometimes'  id='choice_37_96_2'    \/>\n\t\t\t\t<label for='choice_37_96_2' id='label_37_96_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_96_3'>\n\t\t\t\t<input name='input_96' type='radio' value='Fairly Often'  id='choice_37_96_3'    \/>\n\t\t\t\t<label for='choice_37_96_3' id='label_37_96_3'>Bastante seguido<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_96_4'>\n\t\t\t\t<input name='input_96' type='radio' value='Frequently'  id='choice_37_96_4'    \/>\n\t\t\t\t<label for='choice_37_96_4' id='label_37_96_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_97\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_97\"><label class='gfield_label'  >\u00bfCon qu\u00e9 frecuencia una persona, incluidos sus familiares y amigos, le grita o le insulta?<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_37_97'>\n\t\t\t<li class='gchoice gchoice_37_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Never'  id='choice_37_97_0'    \/>\n\t\t\t\t<label for='choice_37_97_0' id='label_37_97_0'>Nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='Rarely'  id='choice_37_97_1'    \/>\n\t\t\t\t<label for='choice_37_97_1' id='label_37_97_1'>Casi nunca<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_97_2'>\n\t\t\t\t<input name='input_97' type='radio' value='Sometimes'  id='choice_37_97_2'    \/>\n\t\t\t\t<label for='choice_37_97_2' id='label_37_97_2'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_97_3'>\n\t\t\t\t<input name='input_97' type='radio' value='Fairly Often'  id='choice_37_97_3'    \/>\n\t\t\t\t<label for='choice_37_97_3' id='label_37_97_3'>Bastante seguido<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_97_4'>\n\t\t\t\t<input name='input_97' type='radio' value='Frequently'  id='choice_37_97_4'    \/>\n\t\t\t\t<label for='choice_37_97_4' id='label_37_97_4'>A menudo<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_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_37_98\"><h3 style=\"font-size: 20px; font-weight: 700;margin-top:45px;font-family: 'Rubik';\"><\/h3><\/li><li id=\"field_37_39\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_39'>\n\t\t\t<li class='gchoice gchoice_37_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_37_39_0'    \/>\n\t\t\t\t<label for='choice_37_39_0' id='label_37_39_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_37_39_1'    \/>\n\t\t\t\t<label for='choice_37_39_1' id='label_37_39_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_68\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_68'>\n\t\t\t<li class='gchoice gchoice_37_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_37_68_0'    \/>\n\t\t\t\t<label for='choice_37_68_0' id='label_37_68_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_37_68_1'    \/>\n\t\t\t\t<label for='choice_37_68_1' id='label_37_68_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_69\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_69'>Seleccione todas las que correspondan<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_37_69'><li class='gchoice gchoice_37_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_37_69_1'   aria-describedby=\"gfield_description_37_69\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_1' id='label_37_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_37_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_37_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_2' id='label_37_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_37_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_37_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_3' id='label_37_69_3'>Porque mis hijos tienen Driscoll Health Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_4' id='label_37_69_4'>Porque los amigos\/familiares recomendaron Driscoll Health Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_69_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_5' id='label_37_69_5'>Porque vi un anuncio en la comunidad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_37_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_37_69_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_69_6' id='label_37_69_6'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_71\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_71\"><label class='gfield_label' for='input_37_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_37_71' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_37_67\"  class=\"gfield mt_25 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_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_37_67'>\n\t\t\t<li class='gchoice gchoice_37_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Text'  id='choice_37_67_0'    \/>\n\t\t\t\t<label for='choice_37_67_0' id='label_37_67_0'>Mensaje de texto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='Email'  id='choice_37_67_1'    \/>\n\t\t\t\t<label for='choice_37_67_1' id='label_37_67_1'>Correo electr\u00f3nico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_37_67_2'>\n\t\t\t\t<input name='input_67' type='radio' value='Phone call'  id='choice_37_67_2'    \/>\n\t\t\t\t<label for='choice_37_67_2' id='label_37_67_2'>Llamada telef\u00f3nica<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_37_66\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_66\"><label class='gfield_label' for='input_37_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_37_66' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_37_59\"  class=\"gfield mt_25 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_59\"><label class='gfield_label' for='input_37_59' >Comentarios adicionales:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_37_59' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_37_34\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_37_34\"><div class='ginput_container ginput_container_text'><input name='input_34' id='input_37_34' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_37_99\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_37_99\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_37_99' >PriorProblems<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_37_99' type='text' value='Problems with prior pregnancy&lt;br&gt;' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_37_100\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_37_100\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_37_100' >HealthProbEsc<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_37_100' type='text' value='Additional health problems (diabetes, depression heart disease or kidney disease) &lt;br&gt;' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_37_101\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_37_101\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_37_101' >SocialEsc<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_37_101' type='text' value='Needs Social Work assistance&lt;br&gt;' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_37_102\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_37_102\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_37_102' >FoodInsecurity<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_37_102' type='text' value='Food insecurity&lt;br&gt;' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_37_103\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden\"  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