{"id":5289,"date":"2025-02-10T16:34:02","date_gmt":"2025-02-10T15:34:02","guid":{"rendered":"https:\/\/insbrok.com\/cuestionario-adicional-de-sanitas\/"},"modified":"2025-02-10T16:34:02","modified_gmt":"2025-02-10T15:34:02","slug":"cuestionario-adicional-de-sanitas","status":"publish","type":"page","link":"https:\/\/insbrok.com\/es\/cuestionario-adicional-de-sanitas\/","title":{"rendered":"Cuestionario adicional de Sanitas"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_75' style='display:none'><div id='gf_75' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_75'  action='\/es\/wp-json\/wp\/v2\/pages\/5289#gf_75' data-formid='75' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_75_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_75' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_75_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Este cuestionario debe cumplimentarse por cada beneficiario que declare problemas de salud. En caso de extracci\u00f3n de \u00f3rganos y\/o tejidos, tambi\u00e9n debe aportarse la anatom\u00eda patol\u00f3gica, as\u00ed como el informe m\u00e9dico con la situaci\u00f3n actual. Si tienes informes m\u00e9dicos de los problemas declarados, adj\u00fantalos.  <\/div><div id=\"field_75_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_75_21'>QR Entry<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_75_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_75_64'>Contract Entry (Sanitas)<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_75_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_75_22'>Compa\u00f1ia<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_75_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_75_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre del asegurado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_75_1'>\n                            \n                            <span id='input_75_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_75_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre legal completo<\/label>\n                                                    <input type='text' name='input_1.3' id='input_75_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_75_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_75_1_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s) legal(es) completo(s)<\/label>\n                                                            <input type='text' name='input_1.6' id='input_75_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_75_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_2'>N\u00famero de 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_2' id='input_75_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_4\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_4'>Peso en kilogramos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_4' id='input_75_4' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_75_3\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_3'>Altura en cent\u00edmetros<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_3' id='input_75_3' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_75_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_15'>\u00bfTienes alg\u00fan defecto de refracci\u00f3n \u00f3ptica (miop\u00eda, hipermetrop\u00eda, astigmatismo, etc.)? <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_75_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_18'>Dioptr\u00edas ojo derecho<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_75_18' type='text' value='' class='large'    placeholder='0.00' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_19'>Dioptr\u00edas ojo izquierdo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_75_19' type='text' value='' class='large'    placeholder='0.00' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_75_27\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_27'>N\u00famero de Aspectos M\u00e9dicos a declarar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_75_27' type='number' step='any' min='1' max='4' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_75_27\" \/><div class='gfield_description instruction ' id='gfield_instruction_75_27'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>4<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_75_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_75_2' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_75_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_75_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Descripci\u00f3n del Aspecto M\u00e9dico Declarado n\u00ba 1<\/h3><\/div><div id=\"field_75_5\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_5'>1. Causa (por ejemplo, debido a una enfermedad, tras un accidente, cong\u00e9nito, debido al embarazo, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_75_5' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_75_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfInsin\u00faas que es un problema actual o pasado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_75_6'><div class='gchoice gchoice_75_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Current'  id='choice_75_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_6_1' id='label_75_6_1' class='gform-field-label gform-field-label--type-inline'>Actual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_75_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Past'  id='choice_75_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_6_2' id='label_75_6_2' class='gform-field-label gform-field-label--type-inline'>Anterior<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_75_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_7'>Fecha de inicio<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_7' id='input_75_7' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_7_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_7' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_8'>Fecha final<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_8' id='input_75_8' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_8_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_8' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_9\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_9'>2. Localizaci\u00f3n exacta (por ejemplo, pierna izquierda, brazo derecho, orejas, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_75_9' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_10'>3. Tratamiento si lo ha habido, indica el tipo: m\u00e9dico, quir\u00fargico, etc. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_75_10' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_11\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_11'>4. Pr\u00f3tesis o material quir\u00fargico implantado (p. ej., osteos\u00edntesis: clavos, tornillos, mallas, etc.). Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_75_11' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_12'>5. Pruebas diagn\u00f3sticas y\/o tratamientos previstos para el futuro. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_75_12' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_13'>6. Situaci\u00f3n actual respecto al aspecto m\u00e9dico declarado y especificar posibles secuelas (por ejemplo, curado, molestias leves, cojera, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_75_13' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_60\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_75_60'>Please attach relevant medical report(s) if available<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_75_60' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_75_60&quot;,&quot;container&quot;:&quot;gform_multifile_upload_75_60&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_75_60&quot;,&quot;filelist&quot;:&quot;gform_preview_75_60&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/es\\\/?gf_page=803dcb1b73b2593&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Archivos permitidos&quot;,&quot;extensions&quot;:&quot;jpg,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:75,&quot;field_id&quot;:60,&quot;_gform_file_upload_nonce_75_60&quot;:&quot;2c994433bb&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_75_60&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_75_60' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelta archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_75_60' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_75_60\"  >Selecciona archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_75_60'>Tipos de archivos aceptados: jpg, png, pdf, jpeg, m\u00e1x. tama\u00f1o del archivo: 5 MB, N\u00famero m\u00e1ximo de archivos: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_75_60'><\/ul> <div id='gform_preview_75_60' class='ginput_preview_list'><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_75_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_75_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_75_3' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_75_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_75_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Descripci\u00f3n del Aspecto M\u00e9dico Declarado n\u00ba 2<\/h3><\/div><div id=\"field_75_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_29'>1. Causa (por ejemplo, debido a una enfermedad, tras un accidente, cong\u00e9nito, debido al embarazo, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_75_29' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_75_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfInsin\u00faas que es un problema actual o pasado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_75_30'><div class='gchoice gchoice_75_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Current'  id='choice_75_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_30_1' id='label_75_30_1' class='gform-field-label gform-field-label--type-inline'>Actual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_75_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Past'  id='choice_75_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_30_2' id='label_75_30_2' class='gform-field-label gform-field-label--type-inline'>Anterior<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_75_31\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_31'>Fecha de inicio<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_31' id='input_75_31' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_31_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_31_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_31' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_32\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_32'>Fecha final<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_32' id='input_75_32' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_32_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_32_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_32' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_33'>2. Localizaci\u00f3n exacta (por ejemplo, pierna izquierda, brazo derecho, orejas, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_75_33' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_34'>3. Tratamiento si lo ha habido, indica el tipo: m\u00e9dico, quir\u00fargico, etc. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_75_34' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_35'>4. Pr\u00f3tesis o material quir\u00fargico implantado (p. ej., osteos\u00edntesis: clavos, tornillos, mallas, etc.). Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_75_35' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_36'>5. Pruebas diagn\u00f3sticas y\/o tratamientos previstos para el futuro. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_75_36' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_37'>6. Situaci\u00f3n actual respecto al aspecto m\u00e9dico declarado y especificar posibles secuelas (por ejemplo, curado, molestias leves, cojera, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_75_37' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_61\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_75_61'>Please attach relevant medical report(s) if available<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_75_61' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_75_61&quot;,&quot;container&quot;:&quot;gform_multifile_upload_75_61&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_75_61&quot;,&quot;filelist&quot;:&quot;gform_preview_75_61&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/es\\\/?gf_page=803dcb1b73b2593&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Archivos permitidos&quot;,&quot;extensions&quot;:&quot;jpg,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:75,&quot;field_id&quot;:61,&quot;_gform_file_upload_nonce_75_61&quot;:&quot;42d4be87c2&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_75_61&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_75_61' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelta archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_75_61' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_75_61\"  >Selecciona archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_75_61'>Tipos de archivos aceptados: jpg, png, pdf, jpeg, m\u00e1x. tama\u00f1o del archivo: 5 MB, N\u00famero m\u00e1ximo de archivos: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_75_61'><\/ul> <div id='gform_preview_75_61' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_75_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Descripci\u00f3n del Aspecto M\u00e9dico Declarado n\u00ba 3<\/h3><\/div><div id=\"field_75_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_39'>1. Causa (por ejemplo, debido a una enfermedad, tras un accidente, cong\u00e9nito, debido al embarazo, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_75_39' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_75_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfInsin\u00faas que es un problema actual o pasado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_75_54'><div class='gchoice gchoice_75_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Current'  id='choice_75_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_54_1' id='label_75_54_1' class='gform-field-label gform-field-label--type-inline'>Actual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_75_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Past'  id='choice_75_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_54_2' id='label_75_54_2' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_75_55\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_55'>Fecha de inicio<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_55' id='input_75_55' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_55_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_55_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_55' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_56\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_56'>Fecha final<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_56' id='input_75_56' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_56_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_56_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_56' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_40'>2. Localizaci\u00f3n exacta (por ejemplo, pierna izquierda, brazo derecho, orejas, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_75_40' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_41\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_41'>3. Tratamiento si lo ha habido, indica el tipo: m\u00e9dico, quir\u00fargico, etc. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_75_41' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_42'>4. Pr\u00f3tesis o material quir\u00fargico implantado (p. ej., osteos\u00edntesis: clavos, tornillos, mallas, etc.). Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_75_42' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_43'>5. Pruebas diagn\u00f3sticas y\/o tratamientos previstos para el futuro. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_75_43' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_44'>6. Situaci\u00f3n actual respecto al aspecto m\u00e9dico declarado y especificar posibles secuelas (por ejemplo, curado, molestias leves, cojera, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_75_44' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_62\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_75_62'>Please attach relevant medical report(s) if available<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_75_62' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_75_62&quot;,&quot;container&quot;:&quot;gform_multifile_upload_75_62&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_75_62&quot;,&quot;filelist&quot;:&quot;gform_preview_75_62&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/es\\\/?gf_page=803dcb1b73b2593&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Archivos permitidos&quot;,&quot;extensions&quot;:&quot;jpg,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:75,&quot;field_id&quot;:62,&quot;_gform_file_upload_nonce_75_62&quot;:&quot;3e62ecca01&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_75_62&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_75_62' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelta archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_75_62' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_75_62\"  >Selecciona archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_75_62'>Tipos de archivos aceptados: jpg, png, pdf, jpeg, m\u00e1x. tama\u00f1o del archivo: 5 MB, N\u00famero m\u00e1ximo de archivos: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_75_62'><\/ul> <div id='gform_preview_75_62' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_75_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Descripci\u00f3n del Aspecto M\u00e9dico Declarado n\u00ba 4<\/h3><\/div><div id=\"field_75_46\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_46'>1. Causa (por ejemplo, debido a una enfermedad, tras un accidente, cong\u00e9nito, debido al embarazo, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_75_46' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_75_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfInsin\u00faas que es un problema actual o pasado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_75_57'><div class='gchoice gchoice_75_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Current'  id='choice_75_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_57_1' id='label_75_57_1' class='gform-field-label gform-field-label--type-inline'>Actual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_75_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Past'  id='choice_75_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_75_57_2' id='label_75_57_2' class='gform-field-label gform-field-label--type-inline'>Anterior<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_75_58\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_58'>Fecha de inicio<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_58' id='input_75_58' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_58_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_58_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_58' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_59\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_59'>Fecha final<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_59' id='input_75_59' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_75_59_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_75_59_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_75_59' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_75_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_47'>2. Localizaci\u00f3n exacta (por ejemplo, pierna izquierda, brazo derecho, orejas, etc.). Especifica <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_75_47' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_48'>3. Tratamiento si lo ha habido, indica el tipo: m\u00e9dico, quir\u00fargico, etc. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_75_48' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_49\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_49'>4. Pr\u00f3tesis o material quir\u00fargico implantado (p. ej., osteos\u00edntesis: clavos, tornillos, mallas, etc.). Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_75_49' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_50'>5. Pruebas diagn\u00f3sticas y\/o tratamientos previstos para el futuro. Especifica. <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_75_50' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_75_51'>6. Situaci\u00f3n actual respecto al aspecto m\u00e9dico declarado y especificar posibles secuelas (por ejemplo, curado, molestias leves, cojera, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_75_51' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_75_63\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_75_63'>Please attach relevant medical report(s) if available<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_75_63' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_75_63&quot;,&quot;container&quot;:&quot;gform_multifile_upload_75_63&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_75_63&quot;,&quot;filelist&quot;:&quot;gform_preview_75_63&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/es\\\/?gf_page=803dcb1b73b2593&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/insbrok.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Archivos permitidos&quot;,&quot;extensions&quot;:&quot;jpg,png,pdf,jpeg&quot;}],&quot;max_file_size&quot;:&quot;5242880b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:75,&quot;field_id&quot;:63,&quot;_gform_file_upload_nonce_75_63&quot;:&quot;f85dac9ac8&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_75_63&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_75_63' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelta archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_75_63' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_75_63\"  >Selecciona archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_75_63'>Tipos de archivos aceptados: jpg, png, pdf, jpeg, m\u00e1x. tama\u00f1o del archivo: 5 MB, N\u00famero m\u00e1ximo de archivos: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_75_63'><\/ul> <div id='gform_preview_75_63' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_75_52\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Firma<\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_52' id='input_75_52_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_75_52_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_75_52\" width=\"300\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/insbrok.com\/wp-content\/plugins\/formecho-signature-add-on\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_75_52_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_75_52_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' role='button' tabindex='0' aria-label='Clear Signature' \/><\/div><input type='hidden' id='input_75_52_data' name='input_75_52_data' value=''><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_75' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='submit' id='gform_submit_button_75' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_75' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' 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