{"id":7313,"date":"2023-02-07T12:21:12","date_gmt":"2023-02-07T20:21:12","guid":{"rendered":"https:\/\/mothertobaby.org\/?page_id=7313"},"modified":"2023-10-02T09:05:30","modified_gmt":"2023-10-02T16:05:30","slug":"refiere-paciente-form","status":"publish","type":"page","link":"https:\/\/mothertobaby.org\/es\/refiere-paciente-form\/","title":{"rendered":"Refiere a un Paciente"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\" id=\"h-ayudando-a-educar-a-sus-pacientes-durante-el-embarazo-y-la-lactancia\"><strong><strong>Ayudando a Educar a sus Pacientes Durante el Embarazo y la Lactancia<\/strong><\/strong><\/h2>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>Por favor, proporci\u00f3nenos la siguiente informaci\u00f3n para que podamos contactar a su paciente.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_14' class='form-refer-patient' action='\/es\/wp-json\/wp\/v2\/pages\/7313' data-formid='14' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_48\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_48'>URL<\/label><div class='ginput_container'><input name='input_48' id='input_14_48' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_14_48'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_14_23\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_23'>Estoy refiriendo a mi paciente por:<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_14_23' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='Asesoramiento sobre exposici\u00f3n \/ informaci\u00f3n' >Asesoramiento sobre exposici\u00f3n \/ informaci\u00f3n<\/option><option value='Participaci\u00f3n en un estudio' >Participaci\u00f3n en un estudio<\/option><option value='Tanto asesoramiento como participaci\u00f3n en un estudio' >Tanto asesoramiento como participaci\u00f3n en un estudio<\/option><\/select><\/div><\/div><fieldset id=\"field_14_1\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' > Al marcar la casilla a continuaci\u00f3n, confirma que el paciente acepta ser contactado por MotherToBaby:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_1'><div class='gchoice gchoice_14_1_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.1' type='checkbox'  value='S\u00ed, el paciente acepta ser contactado'  id='choice_14_1_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_1_1' id='label_14_1_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, el paciente acepta ser contactado<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_2\" class=\"gfield gfield--type-text gfield--input-type-text name gf-add-placeholder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_2'>Nombre del Paciente<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_14_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_31\" class=\"gfield gfield--type-email gfield--input-type-email email gf-add-placeholder gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' > Correo Electr\u00f3nico del Paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_14_31_container'>\n                                <span id='input_14_31_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_31' id='input_14_31' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_14_31' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_14_31_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_31_2' id='input_14_31_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_14_31_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_14_3\" class=\"gfield gfield--type-phone gfield--input-type-phone phone gf-add-placeholder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_3'>Tel\u00e9fono del Paciente<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_14_3' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_36\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_36'>\u00bfCu\u00e1l es la zona horaria del paciente?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_14_36' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='Alaska (Anchorage)' >Alaska (Anchorage)<\/option><option value='Atl\u00e1ntico (San Juan)' >Atl\u00e1ntico (San Juan)<\/option><option value='Central (Houston)' >Central (Houston)<\/option><option value='Este (Nueva York)' >Este (Nueva York)<\/option><option value='Hawaii (Honolulu)' >Hawaii (Honolulu)<\/option><option value='Monta\u00f1a (Denver)' >Monta\u00f1a (Denver)<\/option><option value='Pac\u00edfico (Los Angeles)' >Pac\u00edfico (Los Angeles)<\/option><option value='Samoa (Apia)' >Samoa (Apia)<\/option><\/select><\/div><\/div><fieldset id=\"field_14_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Idioma del Paciente<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_32'>\n\t\t\t<div class='gchoice gchoice_14_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Ingl\u00e9s'  id='choice_14_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_32_0' id='label_14_32_0' class='gform-field-label gform-field-label--type-inline'>Ingl\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Espa\u00f1ol'  id='choice_14_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_32_1' id='label_14_32_1' class='gform-field-label gform-field-label--type-inline'>Espa\u00f1ol<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Franc\u00e9s'  id='choice_14_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_32_2' id='label_14_32_2' class='gform-field-label gform-field-label--type-inline'>Franc\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='gf_other_choice'  id='choice_14_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_32_3' id='label_14_32_3' class='gform-field-label gform-field-label--type-inline'>Otra<\/label><br \/><input id='input_14_32_other' class='gchoice_other_control' name='input_32_other' type='text' value='Otra' aria-label='Si es otro, especif\u00edcalo, por favor'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_6\" class=\"gfield gfield--type-text gfield--input-type-text postalcode gf-add-placeholder gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_6'>C\u00f3digo Postal del Proveedor de Referencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_14_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full postalcode gf-add-placeholder gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_45'>C\u00f3digo Postal del Proveedor de Referencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_14_45' type='text' value='' class='medium'  aria-describedby=\"gfield_description_14_45\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_14_45'>TENGA EN CUENTA. Los servicios de MotherToBaby est\u00e1n disponibles solo para residentes de los Estados Unidos y sus territorios.<\/div><\/div><fieldset id=\"field_14_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Estado del Paciente:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_19'><div class='gchoice gchoice_14_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Actualmente Embarazada'  id='choice_14_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_19_1' id='label_14_19_1' class='gform-field-label gform-field-label--type-inline'>Actualmente Embarazada<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Planeando un Embarazo '  id='choice_14_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_19_2' id='label_14_19_2' class='gform-field-label gform-field-label--type-inline'>Planeando un Embarazo <\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Amamantando'  id='choice_14_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_19_3' id='label_14_19_3' class='gform-field-label gform-field-label--type-inline'>Amamantando<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 el paciente tomando actualmente alg\u00fan medicamento recetado?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_37'>\n\t\t\t<div class='gchoice gchoice_14_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='S\u00ed'  id='choice_14_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_37_0' id='label_14_37_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_14_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_37_1' id='label_14_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_38\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_38'>Por favor enumere los medicamentos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_14_38' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_14_39\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_39'>\u00bfQu\u00e9 edad tiene el beb\u00e9 del paciente?<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_14_39' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='0-3 meses' >0-3 meses<\/option><option value='4-6 meses' >4-6 meses<\/option><option value='7-12 meses' >7-12 meses<\/option><option value='12 meses o m\u00e1s' >12 meses o m\u00e1s<\/option><\/select><\/div><\/div><fieldset id=\"field_14_40\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ubicaci\u00f3n del paciente<\/legend>    \n                    <div class='ginput_complex ginput_container has_city has_zip ginput_container_address gform-grid-row' id='input_14_40' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_40_3_container' >\n                                    <label for='input_14_40_3' id='input_14_40_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                    <input type='text' name='input_40.3' id='input_14_40_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_40.4' id='input_14_40_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_14_40_5_container' >\n                                    <label for='input_14_40_5' id='input_14_40_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                    <input type='text' name='input_40.5' id='input_14_40_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_40.6' id='input_14_40_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_14_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si est\u00e1 embarazada, fecha estimada de parto:<\/legend><div id='input_14_24' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_14_24_1_container'>\n                                            <input type='number' maxlength='2' name='input_24[]' id='input_14_24_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_14_24_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_14_24_2_container'>\n                                            <input type='number' maxlength='2' name='input_24[]' id='input_14_24_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_14_24_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_14_24_3_container'>\n                                            <input type='number' maxlength='4' name='input_24[]' id='input_14_24_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                            <label for='input_14_24_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_14_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTiene el paciente alguna de las siguientes condiciones m\u00e9dicas (marque todas las que correspondan):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_20'><div class='gchoice gchoice_14_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Asthma'  id='choice_14_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_1' id='label_14_20_1' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Ankylosing Spondylitis'  id='choice_14_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_2' id='label_14_20_2' class='gform-field-label gform-field-label--type-inline'>Ankylosing Spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Atopic Dermatitis'  id='choice_14_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_3' id='label_14_20_3' class='gform-field-label gform-field-label--type-inline'>Atopic Dermatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Coronavirus (COVID-19)'  id='choice_14_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_4' id='label_14_20_4' class='gform-field-label gform-field-label--type-inline'>Coronavirus (COVID-19)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Crohn&#039;s Disease'  id='choice_14_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_5' id='label_14_20_5' class='gform-field-label gform-field-label--type-inline'>Crohn&#8217;s Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Hidradenitis Suppurativa'  id='choice_14_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_6' id='label_14_20_6' class='gform-field-label gform-field-label--type-inline'>Hidradenitis Suppurativa<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Lupus'  id='choice_14_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_7' id='label_14_20_7' class='gform-field-label gform-field-label--type-inline'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Multiple Sclerosis'  id='choice_14_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_8' id='label_14_20_8' class='gform-field-label gform-field-label--type-inline'>Multiple Sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='Non-Radiographic Axial Spondyloarthritis'  id='choice_14_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_9' id='label_14_20_9' class='gform-field-label gform-field-label--type-inline'>Non-Radiographic Axial Spondyloarthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.11' type='checkbox'  value='Psoriasis'  id='choice_14_20_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_11' id='label_14_20_11' class='gform-field-label gform-field-label--type-inline'>Psoriasis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.12' type='checkbox'  value='Psoriatic Arthritis'  id='choice_14_20_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_12' id='label_14_20_12' class='gform-field-label gform-field-label--type-inline'>Psoriatic Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.13' type='checkbox'  value='Ulcerative Colitis'  id='choice_14_20_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_13' id='label_14_20_13' class='gform-field-label gform-field-label--type-inline'>Ulcerative Colitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.14' type='checkbox'  value='Otro (liste en los comentarios abajo)'  id='choice_14_20_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_14' id='label_14_20_14' class='gform-field-label gform-field-label--type-inline'>Otro (liste en los comentarios abajo)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_20_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.15' type='checkbox'  value='Patient does not have any health conditions'  id='choice_14_20_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_20_15' id='label_14_20_15' class='gform-field-label gform-field-label--type-inline'>Patient does not have any health conditions<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_16\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_16'>Comentarios:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_14_16' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_14_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfEl paciente ha estado expuesto a la vacuna COVID-19?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_21'><div class='gchoice gchoice_14_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='S\u00ed'  id='choice_14_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_1' id='label_14_21_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_14_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_2' id='label_14_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfLa paciente ha estado expuesta a la vacuna contra la tos ferina?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_33'><div class='gchoice gchoice_14_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='S\u00ed'  id='choice_14_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_33_1' id='label_14_33_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='No'  id='choice_14_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_33_2' id='label_14_33_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_34\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_34'>Soy un:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_14_34' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='Healthcare provider' >Healthcare provider<\/option><option value='MotherToBaby counselor' >MotherToBaby counselor<\/option><\/select><\/div><\/div><div id=\"field_14_46\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_46'>Especialidad<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_14_46' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Alerg\u00f3logo\/Inmun\u00f3logo' >Alerg\u00f3logo\/Inmun\u00f3logo<\/option><option value='Cardi\u00f3logo\/Lipid\u00f3logo' >Cardi\u00f3logo\/Lipid\u00f3logo<\/option><option value='Coordinador de Investigaci\u00f3n Cl\u00ednica' >Coordinador de Investigaci\u00f3n Cl\u00ednica<\/option><option value='Trabajador de Salud Comunitaria' >Trabajador de Salud Comunitaria<\/option><option value='Dermat\u00f3logo' >Dermat\u00f3logo<\/option><option value='Doula' >Doula<\/option><option value='Endocrin\u00f3logo' >Endocrin\u00f3logo<\/option><option value='Proveedor de Medicina Familiar' >Proveedor de Medicina Familiar<\/option><option value='Gastroenter\u00f3logo' >Gastroenter\u00f3logo<\/option><option value='Asesor Gen\u00e9tico' >Asesor Gen\u00e9tico<\/option><option value='Educador de salud' >Educador de salud<\/option><option value='Hemat\u00f3logo' >Hemat\u00f3logo<\/option><option value='Especialista en Medicina Interna' >Especialista en Medicina Interna<\/option><option value='Consultor de Lactancia' >Consultor de Lactancia<\/option><option value='Especialista en Medicina Materno-Fetal' >Especialista en Medicina Materno-Fetal<\/option><option value='Partera' >Partera<\/option><option value='Neur\u00f3logo' >Neur\u00f3logo<\/option><option value='NMMHH Counselor' >NMMHH Counselor<\/option><option value='Enfermero\/a' >Enfermero\/a<\/option><option value='Enfermero\/a Practicante' >Enfermero\/a Practicante<\/option><option value='Obstetra' >Obstetra<\/option><option value='Onc\u00f3logo' >Onc\u00f3logo<\/option><option value='Pediatra' >Pediatra<\/option><option value='Asistente M\u00e9dico' >Asistente M\u00e9dico<\/option><option value='Farmac\u00e9utico\/Toxic\u00f3logo' >Farmac\u00e9utico\/Toxic\u00f3logo<\/option><option value='Proveedor de Atenci\u00f3n Primaria' >Proveedor de Atenci\u00f3n Primaria<\/option><option value='Psiquiatra\/Psic\u00f3logo' >Psiquiatra\/Psic\u00f3logo<\/option><option value='Neum\u00f3logo' >Neum\u00f3logo<\/option><option value='Reumat\u00f3logo' >Reumat\u00f3logo<\/option><option value='Otro (Por favor especifique en el cuadro de comentarios)' >Otro (Por favor especifique en el cuadro de comentarios)<\/option><\/select><\/div><\/div><div id=\"field_14_35\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_35'>Seleccione la ubicaci\u00f3n de MTB<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_14_35' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='MotherToBaby Arizona' >MotherToBaby Arizona<\/option><option value='MotherToBaby California' >MotherToBaby California<\/option><option value='MotherToBaby Connecticut' >MotherToBaby Connecticut<\/option><option value='MotherToBaby Florida' >MotherToBaby Florida<\/option><option value='MotherToBaby Georgia' >MotherToBaby Georgia<\/option><option value='MotherToBaby Nebraska' >MotherToBaby Nebraska<\/option><option value='MotherToBaby New York' >MotherToBaby New York<\/option><option value='MotherToBaby North Carolina' >MotherToBaby North Carolina<\/option><option value='MotherToBaby North Texas' >MotherToBaby North Texas<\/option><option value='MotherToBaby Texas TIPS' >MotherToBaby Texas TIPS<\/option><option value='MotherToBaby UR Medicine' >MotherToBaby UR Medicine<\/option><option value='MotherToBaby Utah' >MotherToBaby Utah<\/option><option value='Centre IMAGe: Info-Medicaments en Allaitement et Grossesse' >Centre IMAGe: Info-Medicaments en Allaitement et Grossesse<\/option><\/select><\/div><\/div><div id=\"field_14_10\" class=\"gfield gfield--type-text gfield--input-type-text name gf-add-placeholder gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_10'>Tu Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_14_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_11\" class=\"gfield gfield--type-phone gfield--input-type-phone phone gf-add-placeholder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_11'>Su n\u00famero de tel\u00e9fono<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_14_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_12\" class=\"gfield gfield--type-email gfield--input-type-email email gf-add-placeholder gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_12'>Tu 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_12' id='input_14_12' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_14_14\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_14'>\u00bfC\u00f3mo supiste de nosotros? <\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_14_14' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='Google\/Busqueda de Internet' >Google\/Busqueda de Internet<\/option><option value='Colega\/Compa\u00f1ero Proveedor de Salud' >Colega\/Compa\u00f1ero Proveedor de Salud<\/option><option value='Consejera de MotherToBaby' >Consejera de MotherToBaby<\/option><option value='Organizaci\u00f3n sin \u00e1nimo de lucro (National MS Society, Arthritis Foundation, etc.)' >Organizaci\u00f3n sin \u00e1nimo de lucro (National MS Society, Arthritis Foundation, etc.)<\/option><option value='Grupo de Apoyo\/Defensor\u00eda del Paciente (MyHealthTeams, PatientsLikeMe, etc.)' >Grupo de Apoyo\/Defensor\u00eda del Paciente (MyHealthTeams, PatientsLikeMe, etc.)<\/option><option value='Sociedad Profesional\/Conferencia (ACOG, ACR, AAD, ACG, AAN, ACNM, SMFM, Pri-Med, etc.)' >Sociedad Profesional\/Conferencia (ACOG, ACR, AAD, ACG, AAN, ACNM, SMFM, Pri-Med, etc.)<\/option><option value='Compa\u00f1\u00eda farmac\u00e9utica\/Etiqueta del medicamento' >Compa\u00f1\u00eda farmac\u00e9utica\/Etiqueta del medicamento<\/option><option value='Medios Sociales (Facebook, Twitter, etc.)' >Medios Sociales (Facebook, Twitter, etc.)<\/option><option value='Otro (Por favor especifique debajo)' >Otro (Por favor especifique debajo)<\/option><\/select><\/div><\/div><div id=\"field_14_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_47'>Especialidad<\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_14_47' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Alerg\u00f3logo\/Inmun\u00f3logo' >Alerg\u00f3logo\/Inmun\u00f3logo<\/option><option value='Cardi\u00f3logo\/Lipid\u00f3logo' >Cardi\u00f3logo\/Lipid\u00f3logo<\/option><option value='Coordinador de Investigaci\u00f3n Cl\u00ednica' >Coordinador de Investigaci\u00f3n Cl\u00ednica<\/option><option value='Trabajador de Salud Comunitaria' >Trabajador de Salud Comunitaria<\/option><option value='Dermat\u00f3logo' >Dermat\u00f3logo<\/option><option value='Doula' >Doula<\/option><option value='Endocrin\u00f3logo' >Endocrin\u00f3logo<\/option><option value='Proveedor de Medicina Familiar' >Proveedor de Medicina Familiar<\/option><option value='Gastroenter\u00f3logo' >Gastroenter\u00f3logo<\/option><option value='Asesor Gen\u00e9tico' >Asesor Gen\u00e9tico<\/option><option value='Educador de salud' >Educador de salud<\/option><option value='Hemat\u00f3logo' >Hemat\u00f3logo<\/option><option value='Especialista en Medicina Interna' >Especialista en Medicina Interna<\/option><option value='Consultor de Lactancia' >Consultor de Lactancia<\/option><option value='Especialista en Medicina Materno-Fetal' >Especialista en Medicina Materno-Fetal<\/option><option value='Partera' >Partera<\/option><option value='Neur\u00f3logo' >Neur\u00f3logo<\/option><option value='NMMHH Counselor' >NMMHH Counselor<\/option><option value='Enfermero\/a' >Enfermero\/a<\/option><option value='Enfermero\/a Practicante' >Enfermero\/a Practicante<\/option><option value='Obstetra' >Obstetra<\/option><option value='Onc\u00f3logo' >Onc\u00f3logo<\/option><option value='Pediatra' >Pediatra<\/option><option value='Asistente M\u00e9dico' >Asistente M\u00e9dico<\/option><option value='Farmac\u00e9utico\/Toxic\u00f3logo' >Farmac\u00e9utico\/Toxic\u00f3logo<\/option><option value='Proveedor de Atenci\u00f3n Primaria' >Proveedor de Atenci\u00f3n Primaria<\/option><option value='Psiquiatra\/Psic\u00f3logo' >Psiquiatra\/Psic\u00f3logo<\/option><option value='Neum\u00f3logo' >Neum\u00f3logo<\/option><option value='Reumat\u00f3logo' >Reumat\u00f3logo<\/option><option value='Otro (Por favor especifique en el cuadro de comentarios)' >Otro (Por favor especifique en el cuadro de comentarios)<\/option><\/select><\/div><\/div><div id=\"field_14_42\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_42'>\u00bfC\u00f3mo se comunic\u00f3 con un consejero(a) de MotherToBaby?<\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_14_42' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='Correo Electr\u00f3nico ' >Correo Electr\u00f3nico <\/option><option value='En persona' >En persona<\/option><option value='Chat en vivo en la p\u00e1gina web de MotherToBaby' >Chat en vivo en la p\u00e1gina web de MotherToBaby<\/option><option value='N\u00famero de Tel\u00e9fono ' >N\u00famero de Tel\u00e9fono <\/option><option value='Texto' >Texto<\/option><option value='Redes Sociales' >Redes Sociales<\/option><\/select><\/div><\/div><div id=\"field_14_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_43'>Si lo sabe, proporcione el nombre del consejero(a) de MotherToBaby con quien se comunic\u00f3: (Opcional)<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_14_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_44\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_44'>Seleccione la ubicaci\u00f3n de MotherToBaby quien le informo acerca de nosotros: (Opcional)<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_14_44' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Uno<\/option><option value='MotherToBaby Arizona' >MotherToBaby Arizona<\/option><option value='MotherToBaby California' >MotherToBaby California<\/option><option value='MotherToBaby Connecticut' >MotherToBaby Connecticut<\/option><option value='MotherToBaby Florida' >MotherToBaby Florida<\/option><option value='MotherToBaby Georgia' >MotherToBaby Georgia<\/option><option value='MotherToBaby Massachusetts' >MotherToBaby Massachusetts<\/option><option value='MotherToBaby Nebraska' >MotherToBaby Nebraska<\/option><option value='MotherToBaby New York' >MotherToBaby New York<\/option><option value='MotherToBaby North Carolina' >MotherToBaby North Carolina<\/option><option value='MotherToBaby North Texas' >MotherToBaby North Texas<\/option><option value='MotherToBaby Texas TIPS' >MotherToBaby Texas TIPS<\/option><option value='MotherToBaby UR Medicine' >MotherToBaby UR Medicine<\/option><option value='MotherToBaby Utah' >MotherToBaby Utah<\/option><option value='Centre IMAGe (Montreal, Quebec, Canad\u00e1)' >Centre IMAGe (Montreal, Quebec, Canad\u00e1)<\/option><option value='Desconocido' >Desconocido<\/option><\/select><\/div><\/div><div id=\"field_14_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_15'>Comentarios:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_14_15' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_14_26\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_26' id='input_14_26' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='Ciudad' \/><\/div><\/div><div id=\"field_14_27\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_27' id='input_14_27' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='Estado' \/><\/div><\/div><div id=\"field_14_28\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_28' id='input_14_28' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='Pa\u00eds' \/><\/div><\/div><div id=\"field_14_29\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_29' id='input_14_29' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='Destino' \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' 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